PUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE … · Attachment H - EGWP Formulary RFP ETG0013 – Administrative Services for the State of Wisconsin Pharmacy Benefit Program

Attachment H - EGWP Formulary

RFP ETG0013 – Administrative Services for the State of Wisconsin Pharmacy Benefit Program 1

Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDIT8-MOP CAP 90250560000110 902505600001 N 2abacavir tab 12105005100320 121050051003 Y 2abacavir/lamivudine tab 12109902200340 121099022003 Y 4 ESP NMabacavir/lamivudine/zidovudine tab 12109903200320 121099032003 Y 2ABELCET INJ 11000010301820 110000103018 N M PA_BvDABILIFY DISC TAB 59250015007220 592500150072 N 3 PA_NSO QLABILIFY DISC TAB 59250015007230 592500150072 N 3 PA_NSO QLABILIFY INJ 59250015002050 592500150020 N M PA_NSOABILIFY MAINTENA INJ 59250015001920 592500150019 N M PA_NSOABILIFY MAINTENA INJ 59250015001930 592500150019 N M PA_NSOABILIFY TAB 59250015000305 592500150003 O 3ABILIFY TAB 59250015000310 592500150003 O 3ABILIFY TAB 59250015000320 592500150003 O 3ABILIFY TAB 59250015000330 592500150003 O 3ABILIFY TAB 59250015000340 592500150003 O 3ABILIFY TAB 59250015000350 592500150003 O 3ABRAXANE INJ 21500012201920 215000122019 N M NM PA_BvDABSORICA CAP 90050013000110 900500130001 N MABSORICA CAP 90050013000120 900500130001 N MABSORICA CAP 90050013000125 900500130001 N MABSORICA CAP 90050013000130 900500130001 N MABSORICA CAP 90050013000135 900500130001 N MABSORICA CAP 90050013000140 900500130001 N MABSTRAL TAB 65100025100710 651000251007 N 3 PA QLABSTRAL TAB 65100025100720 651000251007 N 3 PA QLABSTRAL TAB 65100025100725 651000251007 N 3 PA QLABSTRAL TAB 65100025100730 651000251007 N 3 PA QLABSTRAL TAB 65100025100740 651000251007 N 3 PA QLABSTRAL TAB 65100025100750 651000251007 N 3 PA QLacamprosate calcium tab 62802010200620 628020102006 Y 2ACANYA GEL 90059902194030 900599021940 N 3acarbose tab 27500010000310 275000100003 Y 1acarbose tab 27500010000320 275000100003 Y 1acarbose tab 27500010000340 275000100003 Y 1ACCOLATE TAB 44505080000310 445050800003 O 3ACCOLATE TAB 44505080000320 445050800003 O 3ACCU-CHEK ACTIVE METER 50924047701 97202010006400 972020100064 N $0* OTCACCU-CHEK ADVANTAGE METER 50924086001 97202010006410 972020100064 N $0* OTCACCU-CHEK AVIVA TEST STRIPS 65702040710 94100030006100 941000300061 N 20%* OTCACCU-CHEK AVIVA TEST STRIPS 65702040810 94100030006100 941000300061 N 20%* OTCACCU-CHEK AVIVA TEST STRIPS 65702043710 94100030006100 941000300061 N NC OTC



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITACCU-CHEK AVIVA TEST STRIPS 65702043810 94100030006100 941000300061 N NC OTCACCU-CHEK CALIBRATION LIQUID 50924030202 97202007100900 972020071009 N 20%* OTCACCU-CHEK CALIBRATION LIQUID 50924035706 97202007100900 972020071009 N 20%* OTCACCU-CHEK CALIBRATION LIQUID 50924041102 97202007100900 972020071009 N 20%* OTCACCU-CHEK CALIBRATION LIQUID 50924047602 97202007100900 972020071009 N 20%* OTCACCU-CHEK CALIBRATION LIQUID 50924091901 97202007100900 972020071009 N 20%* OTCACCU-CHEK CALIBRATION LIQUID 65702010710 97202007100900 972020071009 N 20%* OTCACCU-CHEK CALIBRATION LIQUID 65702027510 97202007100900 972020071009 N 20%* OTCACCU-CHEK CALIBRATION LIQUID 65702036910 97202007100900 972020071009 N 20%* OTCACCU-CHEK CALIBRATION LIQUID 65702046810 97202007100900 972020071009 N 20%* OTCACCU-CHEK CALIBRATION LIQUID 65702048810 97202007100900 972020071009 N 20%* OTCACCU-CHEK COMPACT METER 50924001901 97202010006400 972020100064 N $0* OTCACCU-CHEK NANO METER 65702048310 97202010006410 972020100064 N $0* OTCACCU-CHEK TEST STRIP 50924036550 94100030006100 941000300061 N NC OTCACCU-CHEK TEST STRIP 50924037350 94100030006100 941000300061 N 20%* OTCACCU-CHEK TEST STRIP 50924038110 94100030006100 941000300061 N 20%* OTCACCU-CHEK TEST STRIP 50924047550 94100030006100 941000300061 N 20%* OTCACCU-CHEK TEST STRIP 50924088110 94100030006100 941000300061 N NC OTCACCU-CHEK TEST STRIP 50924088250 94100030006100 941000300061 N NC OTCACCU-CHEK TEST STRIP 50924088401 94100030006100 941000300061 N 20%* OTCACCU-CHEK TEST STRIP 50924091125 94100030006100 941000300061 N NC OTCACCU-CHEK TEST STRIP 50924091350 94100030006100 941000300061 N NC OTCACCU-CHEK TEST STRIP 50924098850 94100030006100 941000300061 N 20%* OTCACCU-CHEK TEST STRIP 54868324301 94100030006100 941000300061 N NC OTCACCU-CHEK TEST STRIP 65702010310 94100030006100 941000300061 N NC OTCACCU-CHEK TEST STRIP 65702010410 94100030006100 941000300061 N NC OTCACCU-CHEK TEST STRIP 65702010610 94100030006100 941000300061 N NC OTCACCU-CHEK TEST STRIP 65702049210 94100030006100 941000300061 N 20%* OTCACCU-CHEK TEST STRIP 65702049310 94100030006100 941000300061 N 20%* OTCACCU-CHEK TEST STRIP 65702049410 94100030006100 941000300061 N NC OTCACCUPRIL TAB 36100040100305 361000401003 O 3ACCUPRIL TAB 36100040100310 361000401003 O 3ACCUPRIL TAB 36100040100320 361000401003 O 3ACCUPRIL TAB 36100040100340 361000401003 O 3ACCURETIC TAB 36991802650320 369918026503 O 3ACCURETIC TAB 36991802650330 369918026503 O 3ACCURETIC TAB 36991802650335 369918026503 O 3acebutolol cap 33200010100105 332000101001 Y 1acebutolol cap 33200010100110 332000101001 Y 1ACEON TAB 36100035100320 361000351003 O 3ACEON TAB 36100035100330 361000351003 O 3



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITacetaminophen/codeine soln 65991002052020 659910020520 Y 1 QLacetaminophen/codeine tab 65991002050310 659910020503 Y 1 QLacetaminophen/codeine tab 65991002050315 659910020503 Y 1 QLacetaminophen/codeine tab 65991002050320 659910020503 Y 1 QLacetaminophen/isometheptene/dichloral cap 679900031001 Y 1*ACETASOL HC OTIC SOLN 87300020102000 873000201020 N 3acetazolamide cap 37100010006920 371000100069 Y 2acetazolamide inj 37100010102105 371000101021 Y M PA_BvDACETAZOLAMIDE TAB 37100010000305 371000100003 N 1acetazolamide tab 37100010000310 371000100003 Y 1acetic acid otic soln 87400010102010 874000101020 Y 1ACETIC ACID/ALUMINUM ACETATE OTIC SOLN 87400025002010 874000250020 N 1acetic acid/hydrocortisone otic 1-2% 87300020102000 873000201020 Y 1acetylcysteine soln 43300010002003 433000100020 Y 1 PA_BvDacetylcysteine soln 43300010002005 433000100020 Y 1 PA_BvDacitretin cap 90250510000110 902505100001 Y 2acitretin cap 90250510000115 902505100001 Y 2acitretin cap 90250510000125 902505100001 Y 2ACLOVATE CREAM 90550005103710 905500051037 O 3ACTEMRA IV INJ 66500070002035 665000700020 N M NM PAACTEMRA SC INJ 6650007000E520 6650007000E5 N 4 NM PAACTHIB INJ 17200030102100 172000301021 N $0ACTIGALL CAP 52100040000120 521000400001 O 3ACTIMMUNE INJ 21700060702020 217000607020 N 4 ESP NM PA_BvDACTIQ LOZENGE 65100025108450 651000251084 O 3 PA QLACTIQ LOZENGE 65100025108455 651000251084 O 3 PA QLACTIQ LOZENGE 65100025108460 651000251084 O 3 PA QLACTIQ LOZENGE 65100025108465 651000251084 O 3 PA QLACTIQ LOZENGE 65100025108475 651000251084 O 3 PA QLACTIQ LOZENGE 65100025108485 651000251084 O 3 PA QLACTIVELLA TAB 24993002120305 249930021203 O 3ACTIVELLA TAB 24993002120310 249930021203 O 3ACTONEL TAB 30042065100305 300420651003 O 3 STACTONEL TAB 30042065100320 300420651003 O 3 STACTONEL TAB 30042065100330 300420651003 O 3 STACTONEL TAB 30042065100380 300420651003 O 3 STACTOPLUS MET TAB 27998002400320 279980024003 O 3ACTOPLUS MET TAB 27998002400340 279980024003 O 3ACTOPLUS MET XR TAB 27998002407515 279980024075 N 3ACTOPLUS MET XR TAB 27998002407530 279980024075 N 3ACTOS TAB 27607050100320 276070501003 O 3



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITACTOS TAB 27607050100330 276070501003 O 3ACTOS TAB 27607050100340 276070501003 O 3ACULAR LS OPHTH SOLN 86805035102015 868050351020 O 3ACULAR OPHTH SOLN 86805035102020 868050351020 O 3ACUVAIL OPHTH SOLN 86805035102017 868050351020 N 3acyclovir cap 12405010000110 124050100001 Y 1acyclovir inj 12405010102030 124050101020 Y M PA_BvDACYCLOVIR INJ 12405010102120 124050101021 N M PA_BvDacyclovir inj 12405010102120 124050101021 Y M PA_BvDacyclovir ointment 5% 90350010004205 903500100042 Y 2acyclovir susp 12405010001810 124050100018 Y 1acyclovir tab 12405010000320 124050100003 Y 1acyclovir tab 12405010000330 124050100003 Y 1ADACEL INJ 18990003221815 189900032218 N $0ADAGEN INJ 20000050002025 200000500020 N M NM PAADALAT CC ER TAB 34000020007530 340000200075 O 3ADALAT CC ER TAB 34000020007540 340000200075 O 3ADALAT CC ER TAB 34000020007550 340000200075 O 3adapalene cream 90050003003710 900500030037 Y 2 PAadapalene gel 0.1%, 0.3% 90050003004010 900500030040 Y 2 PAadapalene gel 0.1%, 0.3% 90050003004030 900500030040 Y 2 PAADAPALENE LOTION/DIFFERIN LOTION 0.1% 90050003004110 900500030041 M 2 PAADCIRCA TAB 20MG 40143080000320 401430800003 N 4 ESP NM PAADDERALL TAB 61109902100305 611099021003 O 3ADDERALL TAB 61109902100307 611099021003 O 3ADDERALL TAB 61109902100310 611099021003 O 3ADDERALL TAB 61109902100312 611099021003 O 3ADDERALL TAB 61109902100315 611099021003 O 3ADDERALL TAB 61109902100320 611099021003 O 3ADDERALL TAB 61109902100330 611099021003 O 3ADDERALL XR CAP 61109902107005 611099021070 O 2ADDERALL XR CAP 61109902107010 611099021070 O 2ADDERALL XR CAP 61109902107015 611099021070 O 2ADDERALL XR CAP 61109902107020 611099021070 O 2ADDERALL XR CAP 61109902107025 611099021070 O 2ADDERALL XR CAP 61109902107030 611099021070 O 2adefovir dipivoxil tab 12352015100320 123520151003 Y 2ADEMPAS TAB 40134050000310 401340500003 N 4 NM PAADEMPAS TAB 40134050000320 401340500003 N 4 NM PAADEMPAS TAB 40134050000330 401340500003 N 4 NM PAADEMPAS TAB 40134050000340 401340500003 N 4 NM PA



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITADEMPAS TAB 40134050000350 401340500003 N 4 NM PAADRENACLICK INJ 3890004000D540 3890004000D5 M 3 QL STadriamycin inj 21200040102010 212000401020 Y M PA_BvDadrucil inj 21300030002020 213000300020 Y M PA_BvDADVAIR DISKUS 44209902708020 442099027080 N 2 QLADVAIR DISKUS 44209902708030 442099027080 N 2 QLADVAIR DISKUS 44209902708040 442099027080 N 2 QLADVAIR HFA INHALER 44209902703250 442099027032 N 2 QLADVAIR HFA INHALER 44209902703260 442099027032 N 2 QLADVAIR HFA INHALER 44209902703270 442099027032 N 2 QLADVICOR TAB 39409902457520 394099024575 N 3ADVICOR TAB 39409902457525 394099024575 N 3ADVICOR TAB 39409902457530 394099024575 N 3ADVICOR TAB 39409902457535 394099024575 N 3aero otic hydrocortisone soln 879920031220 Y 1*AEROCHAMBER 971000000063 N 20%* OTCAEROCHAMBER 971005500062 N 20%* OTCafeditab tab 34000020007530 340000200075 Y 1afeditab tab 34000020007540 340000200075 Y 1AFINITOR DISPERZ TAB 21532530007310 215325300073 N 4 ESP NM PA_NSOAFINITOR DISPERZ TAB 21532530007320 215325300073 N 4 ESP NM PA_NSOAFINITOR DISPERZ TAB 21532530007340 215325300073 N 4 ESP NM PA_NSOAFINITOR TAB 21532530000310 215325300003 N 4 ESP NM PA_NSO QLAFINITOR TAB 21532530000320 215325300003 N 4 ESP NM PA_NSO QLAFINITOR TAB 21532530000325 215325300003 N 4 ESP NM PA_NSO QLAFINITOR TAB 21532530000330 215325300003 N 4 ESP NM PA_NSO QLAGGRENOX CAP 85159902206920 851599022069 M 2AGRYLIN CAP 85156010100120 851560101001 O 3A-HYDROCORT INJ 22100025402110 221000254021 N M PA_BvDAKYNZEO CAP 50309902290120 503099022901 N 2 PA_BvD QLALA SCALP LOTION 90550075004118 905500750041 O 3ALBATUSSIN LIQUID 439980063009 N 3*ALBENZA TAB 15000002000320 150000020003 N Malbuterol ER tab 44201010107410 442010101074 Y 1albuterol ER tab 44201010107420 442010101074 Y 1albuterol neb 0.083%, 0.5% 44201010102515 442010101025 Y 1 PA_BvDalbuterol neb 0.083%, 0.5% 44201010102520 442010101025 Y 1 PA_BvDalbuterol neb 0.63mg/3ml, 1.25mg/3ml 44201010102555 442010101025 Y 2 PA_BvDalbuterol neb 0.63mg/3ml, 1.25mg/3ml 44201010102560 442010101025 Y 2 PA_BvDalbuterol syrup 44201010101205 442010101012 Y 1albuterol tab 44201010100305 442010101003 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITalbuterol tab 44201010100310 442010101003 Y 1ALCAINE OPHTH SOLN 86750020102005 867500201020 O 3alclometasone cream 90550005103710 905500051037 Y 2alclometasone ointment 90550005104210 905500051042 Y 2ALCOHOL SWABS 97703040004300 977030400043 N 20% OTCALDACTAZIDE TAB 37990002200310 379900022003 O 3ALDACTAZIDE TAB 37990002200320 379900022003 N 3ALDACTONE TAB 37500020000305 375000200003 O 3ALDACTONE TAB 37500020000310 375000200003 O 3ALDACTONE TAB 37500020000315 375000200003 O 3ALDARA CREAM 90773040003720 907730400037 O 3ALDEX TAB 439962023003 Y 3* OTCALDURAZYME INJ 30906550002020 309065500020 N M NM PA_BvDALECENSA CAP 21534007100120 215340071001 N M NM PA_NSOalendronate tab 30042010100305 300420101003 Y 1alendronate tab 30042010100310 300420101003 Y 1alendronate tab 30042010100335 300420101003 Y 1alendronate tab 30042010100370 300420101003 Y 1ALENDRONATE TAB 40MG 30042010100340 300420101003 N 2ALFERON-N INJ 217000603020 N 4* ESPalfuzosin tab 56852010107530 568520101075 Y 1ALIMTA INJ 21300053102120 213000531021 N M NM PA_BvDALINIA SUSP 16400060001920 164000600019 N 2ALINIA TAB 16400060000330 164000600003 N 3ALKERAN INJ 21101040102110 211010401021 O M NM PA_BvDALLEGRA TAB 415500241003 N 3* OTCallopurinol tab 68000010000305 680000100003 Y 1allopurinol tab 68000010000310 680000100003 Y 1almotriptan tab 67406010100320 674060101003 Y M QLalmotriptan tab 67406010100330 674060101003 Y M QLALOCRIL OPHTH SOLN 86802060102020 868020601020 N 2ALOMIDE OPHTH SOLN 86802050202010 868020502020 N 2ALORA/MINIVELLE PATCH 24000035008705 240000350087 N 3ALORA/MINIVELLE PATCH 24000035008710 240000350087 N 3ALORA/MINIVELLE PATCH 24000035008720 240000350087 N 3ALORA/MINIVELLE PATCH 24000035008730 240000350087 N 3ALORA/MINIVELLE PATCH 24000035008750 240000350087 N 3alosetron tab 52554015100310 525540151003 Y 2alosetron tab 52554015100320 525540151003 Y 2ALPHAGAN P OPHTH SOLN 86602020102005 866020201020 N 2ALPHAGAN P OPHTH SOLN 86602020102007 866020201020 O 2



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITalprazolam ER tab 57100010007505 571000100075 Y 2alprazolam ER tab 57100010007510 571000100075 Y 2alprazolam ER tab 57100010007520 571000100075 Y 2alprazolam ER tab 57100010007530 571000100075 Y 2ALPRAZOLAM INTENSOL CONC 57100010001310 571000100013 N Malprazolam ODT tab 57100010007205 571000100072 Y 2alprazolam ODT tab 57100010007210 571000100072 Y 2alprazolam ODT tab 57100010007215 571000100072 Y 2alprazolam ODT tab 57100010007220 571000100072 Y 2alprazolam tab 57100010000305 571000100003 Y 1alprazolam tab 57100010000310 571000100003 Y 1alprazolam tab 57100010000315 571000100003 Y 1alprazolam tab 57100010000320 571000100003 Y 1ALREX OPHTH SUSP 86300035101820 863000351018 N 2ALSUMA INJ 6740607010D520 6740607010D5 N 3 QLALTABAX OINTMENT 90100095004220 901000950042 N 3ALTACE CAP 36100050000110 361000500001 O 3ALTACE CAP 36100050000120 361000500001 O 3ALTACE CAP 36100050000130 361000500001 O 3ALTACE CAP 36100050000140 361000500001 O 3ALTOPREV ER TAB 39400050007520 394000500075 N 3ALTOPREV ER TAB 39400050007530 394000500075 N 3ALTOPREV ER TAB 39400050007540 394000500075 N 3aluminum chloride soln 909700100020 Y 1*amantadine cap 73200010100105 732000101001 Y 1amantadine soln 73200010101205 732000101012 Y 1AMANTADINE TAB 73200010100310 732000101003 N 3AMARYL TAB 27200027000310 272000270003 O 3AMARYL TAB 27200027000320 272000270003 O 3AMARYL TAB 27200027000340 272000270003 O 3AMBIEN TAB 60204080100310 602040801003 O 3 QLAMBIEN TAB 60204080100315 602040801003 O 3 QLAMBISOME INJ 11000010401920 110000104019 N M PA_BvDAMCINONIDE CREAM 0.1% 90550010003705 905500100037 N 2AMCINONIDE LOTION 0.1% 90550010004105 905500100041 N 3AMCINONIDE OINTMENT 0.1% 90550010004205 905500100042 N 2AMERGE TAB 67406050100310 674060501003 O 3 QLAMERGE TAB 67406050100320 674060501003 O 3 QLamethia tab 25993002300330 259930023003 Y $0amethyst tab 25994002350320 259940023503 Y 3AMICAR SYRUP 841000100012 N 3*



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITAMICAR TAB 841000100003 O 3*amifostine inj 21758010102120 217580101021 Y M PA_BvDamikacin inj 07000010102011 070000101020 Y M PA_BvDamikacin inj 07000010102013 070000101020 Y M PA_BvDamiloride tab 37500010100305 375000101003 Y 1amiloride/hydrochlorothiazide tab 37990002100310 379900021003 Y 1aminocaproic acid syrup 841000100012 Y 1*aminocaproic acid tab 500mg 84100010000305 841000100003 Y 1AMINOCAPROIC ACID/AMICAR TAB 1000MG 84100010000320 841000100003 M 2AMINOCAPROIC ACID/AMICAR TAB 1000MG 84100010000320 841000100003 N 2AMINOCAPROIC ACID/AMICAR TAB 500MG 84100010000305 841000100003 N 3*aminophylline inj 44300010002010 443000100020 Y M PA_BvDAMINOSYN II 8.5%/ELECTROLYTE INJ 80302010152045 803020101520 Y M PA_BvDAMINOSYN II INJ 80302010102024 803020101020 N M PA_BvDAMINOSYN II INJ 80302010102030 803020101020 N M PA_BvDAMINOSYN II INJ 80302010102040 803020101020 N M PA_BvDAMINOSYN II INJ 80302010102060 803020101020 O M PA_BvDAMINOSYN II INJ 4.25/D10W 80302010252032 803020102520 N M PA_BvDAMINOSYN II INJ 4.25/D20W 80302010302032 803020103020 N M PA_BvDAMINOSYN II INJ 4.25/D25W 80302010352032 803020103520 N M PA_BvDAMINOSYN INJ 7% 80302010152030 803020101520 N M PA_BvDAMINOSYN M INJ 80302010152015 803020101520 N M PA_BvDaminosyn-hf inj 80302010102025 803020101020 Y M PA_BvDAMINOSYN-RF INJ 5.2% 80302010102015 803020101020 N M PA_BvDamiodarone inj 35400005002030 354000050020 Y M PA_BvDAMIODARONE INJ 35400005112040 354000051120 N M PA_BvDAMIODARONE INJ 35400005112060 354000051120 N M PA_BvDamiodarone tab 35400005000303 354000050003 Y 1amiodarone tab 35400005000305 354000050003 Y 1amiodarone tab 35400005000320 354000050003 Y 1AMITIZA CAP 52450045000110 524500450001 N 3 PAAMITIZA CAP 52450045000120 524500450001 N 3 PAamitriptyline tab 58200010100305 582000101003 Y 1amitriptyline tab 58200010100310 582000101003 Y 1amitriptyline tab 58200010100315 582000101003 Y 1amitriptyline tab 58200010100320 582000101003 Y 1amitriptyline tab 58200010100325 582000101003 Y 1amitriptyline tab 58200010100330 582000101003 Y 1amlodipine tab 34000003100320 340000031003 Y 1amlodipine tab 34000003100330 340000031003 Y 1amlodipine tab 34000003100340 340000031003 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITamlodipine/atorvastatin tab 40992502150305 409925021503 Y Mamlodipine/atorvastatin tab 40992502150310 409925021503 Y Mamlodipine/atorvastatin tab 40992502150315 409925021503 Y Mamlodipine/atorvastatin tab 40992502150320 409925021503 Y Mamlodipine/atorvastatin tab 40992502150325 409925021503 Y Mamlodipine/atorvastatin tab 40992502150330 409925021503 Y Mamlodipine/atorvastatin tab 40992502150335 409925021503 Y Mamlodipine/atorvastatin tab 40992502150350 409925021503 Y Mamlodipine/atorvastatin tab 40992502150355 409925021503 Y Mamlodipine/atorvastatin tab 40992502150360 409925021503 Y Mamlodipine/atorvastatin tab 40992502150365 409925021503 Y Mamlodipine/benazepril cap 36991502200120 369915022001 Y 2amlodipine/benazepril cap 36991502200130 369915022001 Y 2amlodipine/benazepril cap 36991502200140 369915022001 Y 2amlodipine/benazepril cap 36991502200145 369915022001 Y 2amlodipine/benazepril cap 36991502200150 369915022001 Y 2amlodipine/benazepril cap 36991502200160 369915022001 Y 2amlodipine/olmesartan tab 36993002050310 369930020503 Y 3amlodipine/olmesartan tab 36993002050320 369930020503 Y 3amlodipine/olmesartan tab 36993002050330 369930020503 Y 3amlodipine/olmesartan tab 36993002050340 369930020503 Y 3amlodipine/valsartan tab 36993002100310 369930021003 Y 2amlodipine/valsartan tab 36993002100320 369930021003 Y 2amlodipine/valsartan tab 36993002100330 369930021003 Y 2amlodipine/valsartan tab 36993002100340 369930021003 Y 2amlodipine/valsartan/hydrochlorothiazide tab 36994503200320 369945032003 Y 2amlodipine/valsartan/hydrochlorothiazide tab 36994503200325 369945032003 Y 2amlodipine/valsartan/hydrochlorothiazide tab 36994503200330 369945032003 Y 2amlodipine/valsartan/hydrochlorothiazide tab 36994503200335 369945032003 Y 2amlodipine/valsartan/hydrochlorothiazide tab 36994503200340 369945032003 Y 2ammonium chloride inj 79200010002010 792000100020 N M PA_BvDammonium lactate cream 90650015003730 906500150037 Y 1ammonium lactate lotion 90650015004130 906500150041 Y 1AMOXAPINE TAB 58200020000305 582000200003 N 1AMOXAPINE TAB 58200020000310 582000200003 N 1AMOXAPINE TAB 58200020000315 582000200003 N 1AMOXAPINE TAB 58200020000320 582000200003 N 1amoxicillin cap 01200010100105 012000101001 Y 1amoxicillin cap 01200010100110 012000101001 Y 1amoxicillin chew tab 125mg 01200010100505 012000101005 Y 1AMOXICILLIN CHEW TAB 250MG 01200010100510 012000101005 N 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITamoxicillin susp 01200010101910 012000101019 Y 1amoxicillin susp 01200010101913 012000101019 Y 1amoxicillin susp 01200010101915 012000101019 Y 1amoxicillin susp 01200010101924 012000101019 Y 1amoxicillin tab 01200010100303 012000101003 Y 1amoxicillin tab 01200010100315 012000101003 Y 1amoxicillin/k clavulanate chew tab 01990002200515 019900022005 Y 1amoxicillin/k clavulanate chew tab 01990002200535 019900022005 Y 1amoxicillin/k clavulanate ER tab 01990002207420 019900022074 Y 2amoxicillin/k clavulanate susp 01990002201915 019900022019 Y 1amoxicillin/k clavulanate susp 01990002201920 019900022019 Y 1amoxicillin/k clavulanate susp 01990002201935 019900022019 Y 1amoxicillin/k clavulanate susp 01990002201960 019900022019 Y 1amoxicillin/k clavulanate tab 01990002200310 019900022003 Y 1amoxicillin/k clavulanate tab 01990002200320 019900022003 Y 1amoxicillin/k clavulanate tab 01990002200340 019900022003 Y 1amphetamine tab 61109902100305 611099021003 Y 1amphetamine tab 61109902100307 611099021003 Y 1amphetamine tab 61109902100310 611099021003 Y 1amphetamine tab 61109902100312 611099021003 Y 1amphetamine tab 61109902100315 611099021003 Y 1amphetamine tab 61109902100320 611099021003 Y 1amphetamine tab 61109902100330 611099021003 Y 1amphetamine/dextroamphetamine ER cap 61109902107005 611099021070 Y 2amphetamine/dextroamphetamine ER cap 61109902107010 611099021070 Y 2amphetamine/dextroamphetamine ER cap 61109902107015 611099021070 Y 2amphetamine/dextroamphetamine ER cap 61109902107020 611099021070 Y 2amphetamine/dextroamphetamine ER cap 61109902107025 611099021070 Y 2amphetamine/dextroamphetamine ER cap 61109902107030 611099021070 Y 2AMPHOTERICIN INJ 11000010002105 110000100021 N M PA_BvDampicillin cap 01200020200105 012000202001 Y 1ampicillin cap 01200020200110 012000202001 Y 1AMPICILLIN INJ 01200020302105 012000203021 N M PA_BvDampicillin inj 01200020302120 012000203021 Y M PA_BvDampicillin inj 01200020302130 012000203021 Y M PA_BvDampicillin inj 01200020302132 012000203021 Y M PA_BvDampicillin inj 01300040102105 013000401021 Y M PA_BvDampicillin inj 01300040102115 013000401021 Y M PA_BvDampicillin inj 01300040102125 013000401021 Y M PA_BvDampicillin susp 01200020201910 012000202019 Y Mampicillin susp 01200020201915 012000202019 Y M



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITAMPICILLIN/SULBACTAM INJ 01990002252112 019900022521 N M PA_BvDampicillin/sulbactam inj 01990002252112 019900022521 Y M PA_BvDampicillin/sulbactam inj 01990002252120 019900022521 Y M PA_BvDAMPICILLIN/SULBACTAM INJ 01990002252122 019900022521 N M PA_BvDampicillin/sulbactam inj 01990002252152 019900022521 Y M PA_BvDampicillin/sulbactam inj 1.5gm 01990002252110 019900022521 Y MAMPYRA TAB 62406030007420 624060300074 N 4 ESP NM PA QLANADROL TAB 23200050000320 232000500003 N MANAFRANIL CAP 58200025100120 582000251001 O 3ANAFRANIL CAP 58200025100130 582000251001 O 3ANAFRANIL CAP 58200025100140 582000251001 O 3anagrelide cap 85156010100120 851560101001 Y 1anagrelide cap 85156010100130 851560101001 Y 1ANALPRAM-E KIT 899910023164 N 3*ANALPRAM-HC CREAM 899910023137 O 3*ANALPRAM-HC CREAM 899910023164 O 3*ANAPROX DS TAB 66100060100310 661000601003 O 3ANAPROX TAB 66100060100305 661000601003 O 3ANASPAZ TAB 491010301072 O 3*anastrozole tab 21402810000310 214028100003 Y 1ANCOBON CAP 11000020000105 110000200001 O 3ANCOBON CAP 11000020000110 110000200001 O 3ANDRODERM PATCH 2MG 23100030008503 231000300085 N 2 PA QLANDRODERM PATCH 4MG 23100030008510 231000300085 N 2 PA QLANDROGEL 1% (25MG) 23100030004025 231000300040 N 2 PA QLANDROGEL 1% (25MG) 23100030004025 231000300040 O 2 PA QLANDROGEL 1% (50MG) 23100030004030 231000300040 N 2 PA QLANDROGEL 1.62% (1.25GM) 23100030004044 231000300040 N 2 PA QLANDROGEL 1.62% (2.5GM) 23100030004047 231000300040 N 2 PA QLANDROGEL 50MG 23100030004030 231000300040 O 2 PA QLANDROGEL PUMP 1% 23100030004040 231000300040 N 2 PA QLANDROGEL PUMP 1% 23100030004040 231000300040 O 2 PA QLANDROGEL PUMP 1.62% 23100030004050 231000300040 N 2 PA QLANDROID/TESTRED CAP 10MG 23100020000105 231000200001 O 3 PAANGELIQ TAB 24993002400310 249930024003 N 3ANGELIQ TAB 24993002400320 249930024003 N 3ANTABUSE TAB 62802040000325 628020400003 O 2ANTABUSE TAB 62802040000350 628020400003 O 2ANTARA CAP 39200025100103 392000251001 N 3ANTARA CAP 39200025100111 392000251001 N 3antipyrine/benzocaine otic soln 87992002202010 879920022020 Y NC



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITantipyrine/benzocaine otic soln 87992002202012 879920022020 Y NCantipyrine/benzocaine otic soln 54-14mg/ml 879920022020 Y NC

ANTIPYRINE/BENZOCAINE OTIC SOLN 55-14 MG/ML (5.5-1.4%) 879920022020 N NCANTIVERT TAB 50200050000305 502000500003 O 3ANTIVERT TAB 50200050000310 502000500003 O 3ANTIZOL INJ 93000045002010 930000450020 O M NM PA_BvDANUSOL-HC CREAM 89100010003720 891000100037 O 3ANUSOL-HC SUPP 891000101052 O 3*ANZEMET INJ 50250025202020 502500252020 N M PA_BvDANZEMET TAB 50250025200320 502500252003 N 3 PA_BvD QLANZEMET TAB 50250025200330 502500252003 N 3 PA_BvD QLAPEXICON E CREAM 90550050153705 905500501537 N 1APLENZIN TAB 58300040207520 583000402075 N M ST ST_NSOAPLENZIN TAB 58300040207530 583000402075 N M ST ST_NSOAPLENZIN TAB 58300040207540 583000402075 N M ST ST_NSOAPOKYN INJ 73203010102020 732030101020 N 2 NM PA_BvDapraclonidine ophth soln 86602010102010 866020101020 Y 2apri tab 25990002100320 259900021003 Y $0APRISO CAP 52500030007020 525000300070 N 2APTIOM TAB 72600024100320 726000241003 N M PA_NSOAPTIOM TAB 72600024100330 726000241003 N M PA_NSOAPTIOM TAB 72600024100340 726000241003 N M PA_NSOAPTIOM TAB 72600024100360 726000241003 N M PA_NSOAPTIVUS CAP 12104585000120 121045850001 N 4 ESP NMAPTIVUS SOLN 12104585002020 121045850020 N 4 ESP NMARALAST NP INJ 400MG 45100010102108 451000101021 N M NM PA_BvDARALEN TAB 13000010200310 130000102003 O 3aranelle tab 25992002200330 259920022003 Y $0

ARANESP INJ 100MCG, 150MCG, 200MCG, 300MCG, 500MCG 82401015102040 824010151020 N 4 ESP NM PA_BvD ST




ARANESP INJ 100MCG, 150MCG, 200MCG, 300MCG, 500MCG 8240101510E560 8240101510E5 N 4 ESP NM PA_BvD ST




Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDIT



ARANESP INJ 100MCG, 150MCG, 200MCG, 300MCG, 500MCG 8240101510E590 8240101510E5 N 4 ESP NM PA_BvD STARANESP INJ 10MCG, 25MCG, 40MCG, 60MCG 82401015102010 824010151020 N 4 ESP PA_BvD STARANESP INJ 10MCG, 25MCG, 40MCG, 60MCG 82401015102020 824010151020 N 4 ESP PA_BvD STARANESP INJ 10MCG, 25MCG, 40MCG, 60MCG 82401015102030 824010151020 N 4 ESP PA_BvD STARANESP INJ 10MCG, 25MCG, 40MCG, 60MCG 8240101510E510 8240101510E5 N 4 ESP PA_BvD STARANESP INJ 10MCG, 25MCG, 40MCG, 60MCG 8240101510E528 8240101510E5 N 4 ESP PA_BvD STARANESP INJ 10MCG, 25MCG, 40MCG, 60MCG 8240101510E543 8240101510E5 N 4 ESP PA_BvD STARANESP INJ 10MCG, 25MCG, 40MCG, 60MCG 8240101510E552 8240101510E5 N 4 ESP PA_BvD STARAVA TAB 66280050000310 662800500003 O 3ARAVA TAB 66280050000320 662800500003 O 3ARCALYST INJ 66450060002120 664500600021 N M NM PAargatroban inj 83337015002020 833370150020 Y M PA_BvDARGATROBAN INJ 83337015202020 833370152020 N M PA_BvDARGATROBAN INJ 83337015202030 833370152020 N M PA_BvDARICEPT TAB 23MG 62051025100330 620510251003 O 3 QL STARICEPT TAB 5MG, 10MG 62051025100310 620510251003 O 3 QLARICEPT TAB 5MG, 10MG 62051025100320 620510251003 O 3 QLARIMIDEX TAB 21402810000310 214028100003 O 3aripiprazole ODT 59250015007220 592500150072 Y 3 PA_NSO QLaripiprazole ODT 59250015007230 592500150072 Y 3 PA_NSO QLaripiprazole tab 59250015000305 592500150003 Y 2 RXCaripiprazole tab 59250015000310 592500150003 Y 2 RXCaripiprazole tab 59250015000320 592500150003 Y 2 RXCaripiprazole tab 59250015000330 592500150003 Y 2 RXCaripiprazole tab 59250015000340 592500150003 Y 2 RXCaripiprazole tab 59250015000350 592500150003 Y 2 RXCARISTADA 441MG/1.6ML SYR 5925001520E420 5925001520E4 N M NM PA_NSOARISTADA 662MG/2.4ML SYR 5925001520E430 5925001520E4 N M NM PA_NSOARISTADA 882MG/3.2ML SYR 5925001520E440 5925001520E4 N M NM PA_NSOARIXTRA SOLN 2.5MG/0.5ML 83103030102020 831030301020 O 3 PAARIXTRA SOLN 5MG/0.4ML, 7.5MG/0.6ML, 10MG/0.8ML 83103030102035 831030301020 O 3 NM PAARIXTRA SOLN 5MG/0.4ML, 7.5MG/0.6ML, 10MG/0.8ML 83103030102040 831030301020 O 3 NM PAARIXTRA SOLN 5MG/0.4ML, 7.5MG/0.6ML, 10MG/0.8ML 83103030102045 831030301020 O 3 NM PAarmodafinil tab 61400010000310 614000100003 Y 2 PA QLarmodafinil tab 61400010000330 614000100003 Y 2 PA QLarmodafinil tab 61400010000340 614000100003 Y 2 PA QL



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITARMOUR THYROID TAB 281000500003 N 1*ARMOUR THYROID TAB 281000500003 O 1*ARNUITY ELLIPTA INHALER 44400033108020 444000331080 N 1 QLARNUITY ELLIPTA INHALER 44400033108030 444000331080 N 1 QLAROMASIN TAB 21402835000320 214028350003 O 3ARRANON INJ 21300052002020 213000520020 N M PA_BvDARTHROTEC TAB 66109902200620 661099022006 O 3ARTHROTEC TAB 66109902200630 661099022006 O 3ARZERRA INJ 21353045001320 213530450013 N M NM PA_BvDASACOL HD/MESALAMINE TAB 52500030000650 525000300006 M 2ASMANEX HFA INHALER 44400036203220 444000362032 N 1 QLASMANEX HFA INHALER 44400036203230 444000362032 N 1 QLASMANEX INHALER 44400036208010 444000362080 N 1 QLASMANEX INHALER 44400036208020 444000362080 N 1 QLaspirin chew tab 81mg 64100010000510 641000100005 Y $0* OTCaspirin EC tab 81mg, 325mg 64100010000601 641000100006 Y $0* OTCaspirin EC tab 81mg, 325mg 64100010000605 641000100006 O $0* OTCaspirin EC tab 81mg, 325mg 64100010000605 641000100006 Y $0* OTCASPIRIN TAB 81MG 64100010000307 641000100003 N $0* OTCaspirin tab 81mg, 325mg 64100010000307 641000100003 Y $0* OTCaspirin tab 81mg, 325mg 64100010000315 641000100003 Y $0* OTCASTAGRAF XL CAP 99404080007005 994040800070 N M PA_BvDASTAGRAF XL CAP 99404080007010 994040800070 N M PA_BvDASTAGRAF XL CAP 99404080007020 994040800070 N M PA_BvDASTEPRO NASAL SPRAY 42401015102030 424010151020 O 3ASTRAMORPH INJ 65100055102050 651000551020 Y M PA_BvDATACAND HCT TAB 36994002200320 369940022003 O 3ATACAND HCT TAB 36994002200340 369940022003 O 3ATACAND HCT TAB 36994002200350 369940022003 O 3ATACAND TAB 36150020100310 361500201003 O MATACAND TAB 36150020100320 361500201003 O MATACAND TAB 36150020100330 361500201003 O MATACAND TAB 36150020100340 361500201003 O Matamet tab 73209902100330 732099021003 Y 1ATELVIA TAB 30042065100635 300420651006 O 3 STatenolol tab 33200020000303 332000200003 Y 1atenolol tab 33200020000305 332000200003 Y 1atenolol tab 33200020000310 332000200003 Y 1atenolol/chlorthalidone tab 36992002100310 369920021003 Y 1atenolol/chlorthalidone tab 36992002100320 369920021003 Y 1ATGAM INJ 99402540102220 994025401022 N M NM PA_BvD



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITATIVAN TAB 57100060000305 571000600003 O 3ATIVAN TAB 57100060000310 571000600003 O 3ATIVAN TAB 57100060000315 571000600003 O 3atorvastatin tab 39400010100310 394000101003 Y 1atorvastatin tab 39400010100320 394000101003 Y 1atorvastatin tab 39400010100330 394000101003 Y 1atorvastatin tab 39400010100350 394000101003 Y 1atovaquone susp 16400020001820 164000200018 Y 2atovaquone/proguanil tab 13990002050310 139900020503 Y 2atovaquone/proguanil tab 13990002050320 139900020503 Y 2ATRALIN GEL 0.05% 90050030004015 900500300040 O 3 PAATRIPLA TAB 12109903300320 121099033003 N 4 ESP NMATROPINE SULFATE INJ 49101010102005 491010101020 N M PA_BvDatropine sulfate inj 49101010102010 491010101020 Y M PA_BvDatropine sulfate ophth soln 86350010102010 863500101020 Y 1ATROPINE SULFATE OPHTH SOLN 1% 86350010102010 863500101020 N 1ATROVENT HFA INHALER 44100030123420 441000301234 N 2ATROVENT NASAL SOLN 42300040102010 423000401020 O 3ATROVENT NASAL SOLN 42300040102020 423000401020 O 3AUBAGIO TAB 62404070000320 624040700003 N 4 NM PA QLAUBAGIO TAB 62404070000330 624040700003 N 4 NM PA QLaugmented betamethasone cream 90550020053705 905500200537 Y 1augmented betamethasone gel 90550020054005 905500200540 Y 1augmented betamethasone lotion 90550020054105 905500200541 Y 1augmented betamethasone ointment 90550020054205 905500200542 Y 1AUGMENTIN CHEW TAB 400-57MG 01990002200535 019900022005 N 1AUGMENTIN ES SUSP 01990002201960 019900022019 O 3AUGMENTIN SUSP 01990002201910 019900022019 N 3AUGMENTIN SUSP 01990002201920 019900022019 O 3AUGMENTIN TAB 01990002200320 019900022003 O 3AUGMENTIN TAB 01990002200340 019900022003 O 3AUGMENTIN XR TAB 019900022074 O 3*AURALGAN SOLN 879920022020 O NCAURALGAN SOLN 87992002202012 879920022020 N NCAURALGAN SOLN 87992002202012 879920022020 O NCAURYXIA TAB 52800030100320 528000301003 N 3AUVI-Q INJ 3890004000D530 3890004000D5 N 3 QL STAUVI-Q INJ 3890004000D540 3890004000D5 N 3 QL STAVALIDE TAB 36994002300320 369940023003 O 3AVALIDE TAB 36994002300340 369940023003 O 3AVANDAMET TAB 27998002600335 279980026003 N 2



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITAVANDAMET TAB 27998002600350 279980026003 N 2AVANDARYL TAB 27997802600310 279978026003 N 2AVANDARYL TAB 27997802600320 279978026003 N 2AVANDARYL TAB 27997802600360 279978026003 N 2AVANDIA TAB 27607060100320 276070601003 N 2AVANDIA TAB 27607060100330 276070601003 N 2AVANDIA TAB 27607060100340 276070601003 N 2AVAPRO TAB 36150030000310 361500300003 O 3AVAPRO TAB 36150030000320 361500300003 O 3AVAPRO TAB 36150030000340 361500300003 O 3AVAR LS CLEANSER 90059903200918 900599032009 O 3AVASTIN INJ 21335020002025 213350200020 N M NM PA_BvDAVASTIN INJ 21335020002030 213350200020 N M NM PA_BvDAVC VAGINAL CREAM 15% 55100070003705 551000700037 N 2AVELOX INJ 05000037122020 050000371220 N M PA_BvDAVELOX TAB 05000037100320 050000371003 O 3aviane tab 25990002400305 259900024003 Y $0AVINZA CAP 65100055207020 651000552070 O 3 QLAVINZA CAP 65100055207025 651000552070 O 3 QLAVINZA CAP 65100055207030 651000552070 O 3 QLAVINZA CAP 65100055207035 651000552070 O 3 QLAVINZA CAP 65100055207040 651000552070 O 3 QLAVINZA CAP 65100055207050 651000552070 O 3 QLAVODART CAP 56851020000120 568510200001 O 2AVONEX KIT 62403060456420 624030604564 N 4 ESP NM QLAVONEX PEN INJ KIT 30MCG/0.5ML 6240306045F530 6240306045F5 N 4 ESP NM QLAVONEX PREFILLED INJ KIT 30MCG/0.5ML 6240306045F830 6240306045F8 N 4 ESP NM QLAVYCAZ INJ 02990002332120 029900023321 N MAXERT TAB 67406010100320 674060101003 O M QLAXERT TAB 67406010100330 674060101003 O M QLAXID CAP 49200040000120 492000400001 O 3AXID SOLN 49200040002050 492000400020 O 3AXIRON SOLN 23100030002020 231000300020 N 3 PA QLAYGESTIN TAB 26000030100305 260000301003 O 3azacitidine inj 21300003001920 213000030019 Y M PA_BvDAZACTAM INJ 16000005002120 160000050021 O M PA_BvDAZACTAM INJ 16000005002130 160000050021 O M PA_BvDAZACTAM/DEXTROSE INJ 16000005102050 160000051020 N M PA_BvDAZACTAM/DEXTROSE INJ 16000005102060 160000051020 N M PA_BvDAZASAN TAB 99406010000315 994060100003 N 3 PA_BvDAZASAN TAB 99406010000325 994060100003 N 3 PA_BvD



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITAZASITE OPHTH SOLN 86101004002020 861010040020 N 2AZATHIOPRINE INJ 99406010102110 994060101021 N M PA_BvDazathioprine tab 50mg 99406010000305 994060100003 Y 1 PA_BvDazelastine nasal spray 42401015102020 424010151020 Y 2azelastine nasal spray 42401015102030 424010151020 Y 2azelastine ophth soln 86802006102020 868020061020 Y 1AZELEX CREAM 90050005103720 900500051037 N 3 PAAZILECT TAB 73300025200320 733000252003 N 2 RXCAZILECT TAB 73300025200330 733000252003 N 2 RXCazithromycin inj 03400010002120 034000100021 Y M PA_BvDazithromycin susp 03400010001920 034000100019 Y 1azithromycin susp 03400010001930 034000100019 Y 1azithromycin tab 03400010000320 034000100003 Y 1azithromycin tab 03400010000334 034000100003 Y 1azithromycin tab 03400010000340 034000100003 Y 1AZOPT OPHTH SUSP 86802320001820 868023200018 N 2AZOR TAB 36993002050310 369930020503 O 3AZOR TAB 36993002050320 369930020503 O 3AZOR TAB 36993002050330 369930020503 O 3AZOR TAB 36993002050340 369930020503 O 3aztreonam inj 16000005002120 160000050021 Y M PA_BvDAZULFIDINE DR TAB 52500060000610 525000600006 O 3AZULFIDINE TAB 52500060000310 525000600003 O 3bacitracin inj 16000010002110 160000100021 Y M PA_BvDBACITRACIN OPHTH OINTMENT 86101005004205 861010050042 N 2bacitracin/polymyxin ophth ointment 86109902104200 861099021042 Y 1bacitracin/polymyxin/neomcyin/hydrocortisone ophth ointment 86309904104220 863099041042 Y 1baclofen tab 75100010000305 751000100003 Y 1baclofen tab 75100010000310 751000100003 Y 1BACTOCILL/DEXTROSE INJ 01300050112020 013000501120 N M PA_BvDBACTOCILL/DEXTROSE INJ 01300050112030 013000501120 N M PA_BvDBACTRIM DS TAB 16990002300320 169900023003 O 3BACTRIM TAB 16990002300310 169900023003 O 3BACTROBAN CREAM 90100065203710 901000652037 O 3BACTROBAN NASAL OINTMENT 42251050104210 422510501042 N 3BACTROBAN OINTMENT 90100065104210 901000651042 O 3balsalazide cap 52500020100120 525000201001 Y 1balziva tab 25990002500305 259900025003 Y $0BANZEL SUSP 72600065001820 726000650018 N 2BANZEL TAB 72600065000320 726000650003 N 2



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITBANZEL TAB 72600065000330 726000650003 N 2BARACLUDE ORAL SOLN 12352030002020 123520300020 N MBARACLUDE TAB 12352030000320 123520300003 O 3BARACLUDE TAB 12352030000330 123520300003 O 3BCG VACCINE INJ 17200010002200 172000100022 N $0 PA_BvDB-complex multivitamin tab 781330000003 Y 3* OTCBECONASE AQ NASAL SUSP 42200010321810 422000103218 N 3 QL STBELEODAQ INJ 21531520002120 215315200021 N M NM PA_NSObenazepril tab 36100005100310 361000051003 Y 1benazepril tab 36100005100320 361000051003 Y 1benazepril tab 36100005100330 361000051003 Y 1benazepril tab 36100005100340 361000051003 Y 1benazepril/hydrochlorothiazide tab 36991802150310 369918021503 Y 1benazepril/hydrochlorothiazide tab 36991802150320 369918021503 Y 1benazepril/hydrochlorothiazide tab 36991802150330 369918021503 Y 1benazepril/hydrochlorothiazide tab 36991802150340 369918021503 Y 1BENICAR HCT TAB 36994002500320 369940025003 O 3BENICAR HCT TAB 36994002500340 369940025003 O 3BENICAR HCT TAB 36994002500345 369940025003 O 3BENICAR TAB 36150055200320 361500552003 O 3BENICAR TAB 36150055200340 361500552003 O 3BENICAR TAB 36150055200360 361500552003 O 3BENLYSTA INJ 120MG 99422015002120 994220150021 N M NM PA_BvDBENLYSTA INJ 400MG 99422015002140 994220150021 N M NMBENTYL CAP 49103010100105 491030101001 O 3BENTYL INJ 10MG/ML 49103010102005 491030101020 O M PA_BvDBENTYL TAB 49103010100305 491030101003 O 3BENZACLIN GEL 90059902194020 900599021940 O 3BENZAMYCIN GEL 90059902104010 900599021040 O 3BENZAMYCIN GEL PACK 90059902103010 900599021030 N 3BENZONATATE CAP 431020100001 N 1*benzonatate cap 431020100001 Y 1*benztropine inj 73100010102005 731000101020 Y M PA_BvDbenztropine tab 73100010100305 731000101003 Y 1benztropine tab 73100010100310 731000101003 Y 1benztropine tab 73100010100315 731000101003 Y 1BEPREVE OPHTH SOLN 86802008102020 868020081020 N 3BERINERT INJ KIT 85802022006420 858020220064 N M NM PABESIVANCE OPHTH SUSP 86101007101820 861010071018 N 3 STBETAGAN OPHTH SOLN 86250020102005 862500201020 O 3betamethasone dipropionate cream 90550020003705 905500200037 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITbetamethasone dipropionate lotion 90550020004105 905500200041 Y 1betamethasone dipropionate ointment 90550020004205 905500200042 Y 1betamethasone valerate cream 90550020103710 905500201037 Y 1betamethasone valerate foam 90550020103920 905500201039 Y 2betamethasone valerate lotion 90550020104105 905500201041 Y 1betamethasone valerate ointment 90550020104205 905500201042 Y 1BETAPACE AF TAB 33100045120310 331000451203 O 3BETAPACE AF TAB 33100045120315 331000451203 O 3BETAPACE AF TAB 33100045120320 331000451203 O 3BETAPACE TAB 33100045100310 331000451003 O 3BETAPACE TAB 33100045100315 331000451003 O 3BETAPACE TAB 33100045100320 331000451003 O 3BETASERON INJ 50419052309 62403060506420 624030605064 N NCBETASERON INJ 50419052335 62403060506420 624030605064 N NCBETASERON INJ 50419052401 62403060506420 624030605064 N NCBETASERON INJ 50419052435 62403060506420 624030605064 N NCbetaxolol ophth soln 86250010102005 862500101020 Y 1betaxolol tab 33200021100310 332000211003 Y 1betaxolol tab 33200021100320 332000211003 Y 1bethanechol tab 54300010100310 543000101003 Y 1bethanechol tab 54300010100320 543000101003 Y 1bethanechol tab 54300010100330 543000101003 Y 1bethanechol tab 54300010100340 543000101003 Y 1BETIMOL OPHTH SOLN 86250030002020 862500300020 N 2BETIMOL OPHTH SOLN 86250030002030 862500300020 N 2BETOPTIC-S OPHTH SOLN 86250010101810 862500101018 N 2bexarotene cap 21708220000120 217082200001 Y 4 ESP NM PA_NSOBEXSERO INJ 1720004015E620 1720004015E6 N $0BEYAZ TAB 25990003200320 259900032003 O $0BIAXIN SUSP 03500010001920 035000100019 O 3BIAXIN TAB 03500010000310 035000100003 O 3BIAXIN TAB 03500010000320 035000100003 O 3BIAXIN XL TAB 03500010007520 035000100075 O 3bicalutamide tab 21402420000320 214024200003 Y 1BICILLIN CR INJ 01990002101825 019900021018 N M PA_BvDBICILLIN CR INJ 01990002101850 019900021018 N M PA_BvDBICILLIN LA INJ 01100020001815 011000200018 N M PA_BvDBICILLIN LA INJ 01100020001820 011000200018 N M PA_BvDBICILLIN LA INJ 600000 UNIT/ML 01100020001810 011000200018 N MBICNU INJ 21102010002105 211020100021 N M NM PA_BvDBIDIL TAB 40995002400320 409950024003 N M



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITBILTRICIDE TAB 15000050000305 150000500003 N 2BIMATOPROST OPHTH SOLN 0.03% 86330015002020 863300150020 N 2 QLbisoprolol fumarate tab 33200022100310 332000221003 Y 1bisoprolol fumarate tab 33200022100320 332000221003 Y 1bisoprolol/hydrochlorothiazide tab 36992002130310 369920021303 Y 1bisoprolol/hydrochlorothiazide tab 36992002130320 369920021303 Y 1bisoprolol/hydrochlorothiazide tab 36992002130330 369920021303 Y 1BIVIGAM INJ 19100020102072 191000201020 N M NM PABLEO INJ 21200010102150 212000101021 N M PA_BvDbleomycin inj 21200010102115 212000101021 Y M PA_BvDBLEPH-10 OPHTH SOLN 86102010102010 861020101020 O 3BLEPHAMIDE OPHTH SUSP 86309902721810 863099027218 N 2BLEPHAMIDE S.O.P OPHTH OINTMENT 86309902724210 863099027242 N 3BONINE CHEW TAB 502000500005 O 3* OTCBONIVA INJ 30042048102030 300420481020 O M PA_BvD STBONIVA TAB 30042048100360 300420481003 O 3 QL STBOOSTRIX INJ 18990003221820 189900032218 N $0BOSULIF TAB 21534012000320 215340120003 N 4 ESP NM PA_NSOBOSULIF TAB 21534012000340 215340120003 N 4 ESP NM PA_NSOBREO ELLIPTA INHALER 44209902758020 442099027580 N 2 QLBREO ELLIPTA INHALER 44209902758030 442099027580 N 2 QLBREVICON TAB 25990002500310 259900025003 O 3BRILINTA TAB 85158470000315 851584700003 N 3BRILINTA TAB 85158470000320 851584700003 N 3brimonidine ophth soln 86602020102007 866020201020 Y 1brimonidine ophth soln 86602020102010 866020201020 Y 1BRIVIACT INJ 72600015002050 726000150020 N M PA_NSOBRIVIACT SOLN 72600015002020 726000150020 N M PA_NSOBRIVIACT TAB 72600015000310 726000150003 N M PA_NSO QLBRIVIACT TAB 72600015000320 726000150003 N M PA_NSO QLBRIVIACT TAB 72600015000330 726000150003 N M PA_NSO QLBRIVIACT TAB 72600015000340 726000150003 N M PA_NSO QLBRIVIACT TAB 72600015000350 726000150003 N M PA_NSO QLBROMFED DM SYRUP 439958033212 N 3*bromfenac ophth soln 86805005102010 868050051020 Y 2bromfenac ophth soln 86805005102060 868050051020 Y 2BROMFENAC OPHTH SOLN (TWICE DAILY) 0.09% 86805005102010 868050051020 N 2bromocriptine cap 73200020100105 732000201001 Y 2bromocriptine tab 73200020100305 732000201003 Y 2BRONTEX LIQUID 439970022809 N 3* OTCBROVANA NEB SOLN 44201012102520 442010121025 N 3 PA_BvD



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITbudesonide EC cap 22100012006720 221000120067 Y 3 NMbudesonide nasal spray 42200015001810 422000150018 Y 2 QL STbudesonide neb 44400015001830 444000150018 Y 1 PA_BvD QLbudesonide neb 44400015001840 444000150018 Y 1 PA_BvD QLbudesonide neb 44400015001850 444000150018 Y 1 PA_BvD QLbumetanide inj 37200010002005 372000100020 Y M PA_BvDbumetanide tab 37200010000305 372000100003 Y 1bumetanide tab 37200010000310 372000100003 Y 1bumetanide tab 37200010000315 372000100003 Y 1BUNAVAIL FILM 65200010208260 652000102082 N NCBUNAVAIL FILM 65200010208270 652000102082 N NCBUNAVAIL FILM 65200010208280 652000102082 N NCBUPHENYL ORAL POWDER 30908060002950 309080600029 O 3 NMBUPHENYL POWDER 309080600029 O 3*BUPHENYL TAB 309080600003 N 2*BUPRENEX INJ 65200010102005 652000101020 O M PA_BvDbuprenorphine inj 65200010102005 652000101020 Y M PA_BvDbuprenorphine SL tab 65200010100760 652000101007 Y Mbuprenorphine SL tab 65200010100780 652000101007 Y Mbuprenorphine/naloxone SL tab 65200010200720 652000102007 Y 2buprenorphine/naloxone SL tab 65200010200740 652000102007 Y 2buproban tab 62100002107430 621000021074 Y $0bupropion SR tab 58300040107420 583000401074 Y 2bupropion SR tab 58300040107430 583000401074 Y 2bupropion SR tab 58300040107440 583000401074 Y 2bupropion tab 58300040100305 583000401003 Y 1bupropion tab 58300040100310 583000401003 Y 1bupropion XL tab 58300040107520 583000401075 Y 1bupropion XL tab 58300040107530 583000401075 Y 1BUSPAR TAB 572000051003 O 3*buspirone tab 30mg 57200005100340 572000051003 Y NCbuspirone tab 5mg, 10mg, 15mg 57200005100310 572000051003 Y 1buspirone tab 5mg, 10mg, 15mg 57200005100320 572000051003 Y 1buspirone tab 5mg, 10mg, 15mg 57200005100330 572000051003 Y 1buspirone tab 7.5mg 57200005100315 572000051003 Y 1*BUSULFEX INJ 21100010002020 211000100020 N M PA_BvDBUTISOL SODIUM 60100025100310 601000251003 N 3BUTISOL SODIUM 60100025100315 601000251003 N 3butorphanol inj 65200020102005 652000201020 Y M PA_BvDbutorphanol inj 65200020102010 652000201020 Y M PA_BvDbutorphanol nasal spray 10mg/ml 65200020102050 652000201020 Y 2 QL



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITBUTRANS PATCH 65200010008820 652000100088 N 3 QLBUTRANS PATCH 65200010008825 652000100088 N 3 QLBUTRANS PATCH 65200010008830 652000100088 N 3 QLBUTRANS PATCH 65200010008835 652000100088 N 3 QLBUTRANS PATCH 65200010008840 652000100088 N 3 QLBYDUREON INJ 2717002000G220 2717002000G2 N 2BYDUREON PEN INJ 2717002000D120 2717002000D1 N 2BYETTA INJ 2717002000D220 2717002000D2 N 3BYETTA INJ 2717002000D240 2717002000D2 N 3BYSTOLIC TAB 33200040100310 332000401003 N 2 RXCBYSTOLIC TAB 33200040100320 332000401003 N 2 RXCBYSTOLIC TAB 33200040100330 332000401003 N 2 RXCBYSTOLIC TAB 33200040100340 332000401003 N 2 RXCcabergoline tab 30402020000320 304020200003 Y 1CABOMETYX TAB 21534013100320 215340131003 N 4 ESP NM PA_NSOCABOMETYX TAB 21534013100330 215340131003 N 4 ESP NM PA_NSOCABOMETYX TAB 21534013100340 215340131003 N 4 ESP NM PA_NSOCADUET TAB 40992502150305 409925021503 O MCADUET TAB 40992502150310 409925021503 O MCADUET TAB 40992502150315 409925021503 O MCADUET TAB 40992502150320 409925021503 O MCADUET TAB 40992502150325 409925021503 O MCADUET TAB 40992502150330 409925021503 O MCADUET TAB 40992502150335 409925021503 O MCADUET TAB 40992502150350 409925021503 O MCADUET TAB 40992502150355 409925021503 O MCADUET TAB 40992502150360 409925021503 O MCADUET TAB 40992502150365 409925021503 O MCALAN SR TAB 34000030100410 340000301004 O 3CALAN SR TAB 34000030100415 340000301004 O 3CALAN SR TAB 34000030100420 340000301004 O 3CALAN TAB 34000030100305 340000301003 O 3CALAN TAB 34000030100310 340000301003 O 3calcipotriene cream 90250025003710 902500250037 Y 2calcipotriene ointment 90250025004210 902500250042 Y 2calcipotriene soln 90250025002020 902500250020 Y 2calcipotriene/betamethasone ointment 90559902324225 905599023242 Y 2calcitonin nasal spray 30043020002080 300430200020 Y 2calcitriol cap 30905030000105 309050300001 Y 1 PA_BvDcalcitriol cap 30905030000110 309050300001 Y 1 PA_BvDcalcitriol inj 30905030002005 309050300020 Y 2 PA_BvD



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITcalcitriol oral soln 30905030002050 309050300020 Y 1 PA_BvDcalcium acetate cap 52800020100120 528000201001 Y 1calcium acetate tab 52800020100320 528000201003 Y 1CALIBRATION LIQUID 972020071009 N NC OTCcamila tab 25100010000305 251000100003 Y $0CAMPTOSTAR INJ 21550040102025 215500401020 O M PA_BvDCAMPTOSTAR INJ 21550040102030 215500401020 O M PA_BvDCANASA SUPP 52500030005240 525000300052 N 2CANCIDAS INJ 11500025102120 115000251021 N M NM PA_BvDCANCIDAS INJ 11500025102130 115000251021 N M NM PA_BvDcandesartan tab 36150020100310 361500201003 Y 2candesartan tab 36150020100320 361500201003 Y 2candesartan tab 36150020100330 361500201003 Y 2candesartan tab 36150020100340 361500201003 Y 2candesartan/hydrochlorothiazide tab 36994002200320 369940022003 Y 2candesartan/hydrochlorothiazide tab 36994002200340 369940022003 Y 2candesartan/hydrochlorothiazide tab 36994002200350 369940022003 Y 2CANTIL TAB 49102050100305 491020501003 N 3CAPASTAT INJ 09000020102105 090000201021 N M PA_BvDcapecitabine tab 213000050003 Y 4* ESPCAPEX SHAMPOO 90550055104501 905500551045 N 3CAPITAL/CODEINE SUSP 65991002051805 659910020518 N 3 QLCAPRELSA TAB 21534085000320 215340850003 N 2 NM PA_NSOCAPRELSA TAB 21534085000340 215340850003 N 2 NM PA_NSOcaptopril tab 36100010000305 361000100003 Y 1captopril tab 36100010000310 361000100003 Y 1captopril tab 36100010000315 361000100003 Y 1captopril tab 36100010000320 361000100003 Y 1captopril/hydrochlorothiazide tab 36991802250310 369918022503 Y 1CAPTOPRIL/HYDROCHLOROTHIAZIDE TAB 36991802250320 369918022503 N 1captopril/hydrochlorothiazide tab 36991802250330 369918022503 Y 1CAPTOPRIL/HYDROCHLOROTHIAZIDE TAB 36991802250340 369918022503 N 1CARAC CREAM 0.5% 90372030003705 903720300037 M 2CARAFATE SUSP 49300010001820 493000100018 N 1CARAFATE TAB 49300010000305 493000100003 O 3CARBAGLU TAB 30908230000320 309082300003 N Mcarbamazepine chew tab 72600020000505 726000200005 Y 1carbamazepine ER tab 72600020007410 726000200074 Y 2carbamazepine ER tab 72600020007420 726000200074 Y 2carbamazepine ER tab 72600020007440 726000200074 Y 2carbamazepine SR cap 72600020006910 726000200069 Y 2



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITcarbamazepine SR cap 72600020006920 726000200069 Y 2carbamazepine SR cap 72600020006930 726000200069 Y 2carbamazepine susp 72600020001810 726000200018 Y 1carbamazepine tab 72600020000305 726000200003 Y 1CARBATROL SR CAP 72600020006910 726000200069 O 3CARBATROL SR CAP 72600020006920 726000200069 O 3CARBATROL SR CAP 72600020006930 726000200069 O 3carbidopa tab 73403030000320 734030300003 Y 2carbidopa/levodopa ER tab 73209902100410 732099021004 Y 1carbidopa/levodopa ER tab 73209902100420 732099021004 Y 1carbidopa/levodopa ODT 73209902107210 732099021072 Y 1carbidopa/levodopa ODT 73209902107220 732099021072 Y 1carbidopa/levodopa ODT 73209902107230 732099021072 Y 1carbidopa/levodopa tab 73209902100310 732099021003 Y 1carbidopa/levodopa tab 73209902100320 732099021003 Y 1CARBIDOPA/LEVODOPA/ENTACAPONE TAB 73209903300320 732099033003 M 2CARBIDOPA/LEVODOPA/ENTACAPONE TAB 73209903300325 732099033003 M 2CARBIDOPA/LEVODOPA/ENTACAPONE TAB 73209903300330 732099033003 M 2CARBIDOPA/LEVODOPA/ENTACAPONE TAB 73209903300335 732099033003 M 2CARBIDOPA/LEVODOPA/ENTACAPONE TAB 73209903300340 732099033003 M 2CARBIDOPA/LEVODOPA/ENTACAPONE TAB 73209903300350 732099033003 M 2carbinoxamine soln 41200010152030 412000101520 Y 2carbinoxamine tab 41200010150320 412000101503 Y 2carboplatin inj 21100015002030 211000150020 Y M PA_BvDcarboplatin inj 21100015002035 211000150020 Y M PA_BvDcarboplatin inj 21100015002040 211000150020 Y M PA_BvDcarboplatin inj 21100015002045 211000150020 Y M PA_BvDCARDENE INJ 34000018142020 340000181420 N M PA_BvDCARDENE INJ 34000018142040 340000181420 N M PA_BvDCARDIZEM CD CAP 34000010127020 340000101270 O 3CARDIZEM CD CAP 34000010127030 340000101270 O 3CARDIZEM CD CAP 34000010127040 340000101270 O 3CARDIZEM CD CAP 34000010127050 340000101270 O 3CARDIZEM CD CAP 34000010127060 340000101270 O 3CARDIZEM LA TAB 34000010127520 340000101275 N 3CARDIZEM LA TAB 34000010127530 340000101275 O 3CARDIZEM LA TAB 34000010127540 340000101275 O 3CARDIZEM LA TAB 34000010127550 340000101275 O 3CARDIZEM LA TAB 34000010127560 340000101275 O 3CARDIZEM LA TAB 34000010127570 340000101275 O 3CARDIZEM TAB 34000010100305 340000101003 O 3



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITCARDIZEM TAB 34000010100310 340000101003 O 3CARDIZEM TAB 34000010100320 340000101003 O 3CARDURA TAB 36202005100310 362020051003 O 3CARDURA TAB 36202005100320 362020051003 O 3CARDURA TAB 36202005100330 362020051003 O 3CARDURA TAB 36202005100340 362020051003 O 3CARDURA XL TAB 56852025207520 568520252075 N 3CARDURA XL TAB 56852025207530 568520252075 N 3CARIMUNE INJ 19100020102125 191000201021 N M NM PAcarisoprodol tab 75100020000305 751000200003 Y 1carisoprodol/aspirin tab 75990002100310 759900021003 Y 1carisoprodol/aspirin/codeine tab 75990003100310 759900031003 Y 2CARMOL GEL 40% 90660080004040 906600800040 O 3*CARNITOR INJ 30903045102060 309030451020 O M PA_BvDCARNITOR ORAL SOLN 30903045102010 309030451020 O 3 PA_BvDCARNITOR TAB 30903045100330 309030451003 O 3 PA_BvDcarteolol ophth soln 86250012102005 862500121020 Y 1cartia XT cap 34000010127030 340000101270 Y 1carvedilol tab 33300007000305 333000070003 Y 1carvedilol tab 33300007000310 333000070003 Y 1carvedilol tab 33300007000320 333000070003 Y 1carvedilol tab 33300007000330 333000070003 Y 1CASODEX TAB 21402420000320 214024200003 O 3CATAPRES TAB 36201010100305 362010101003 O 3CATAPRES TAB 36201010100310 362010101003 O 3CATAPRES TAB 36201010100315 362010101003 O 3CATAPRES-TTS PATCH 36201010108810 362010101088 O 3CATAPRES-TTS PATCH 36201010108820 362010101088 O 3CATAPRES-TTS PATCH 36201010108830 362010101088 O 3CAVERJECT IMPULSE KIT 00009518101 40303010006410 403030100064 N 4* QLCAVERJECT IMPULSE KIT 00009518201 40303010006420 403030100064 N 4* QLCAVERJECT IMPULSE KIT 54868489000 40303010006420 403030100064 N 4* QLCAVERJECT INJ 00009370105 40303010002120 403030100021 N 4* QLCAVERJECT INJ 00009768601 40303010002140 403030100021 N 4* QLCAVERJECT INJ 00009768604 40303010002140 403030100021 N 4* QLCAYSTON INHALATION SOLN 16000005402120 160000054021 N 2 NM PACEDAX CAP 02300083000120 023000830001 M 3CEDAX SUSP 02300083001920 023000830019 N 3CEDAX SUSP 02300083001940 023000830019 M 3cefaclor cap 02200040000105 022000400001 Y 2cefaclor cap 02200040000110 022000400001 Y 2



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITCEFACLOR ER TAB 02200040107430 022000401074 N 3CEFACLOR SUSP 02200040001905 022000400019 N 2CEFACLOR SUSP 02200040001910 022000400019 N 2CEFACLOR SUSP 02200040001915 022000400019 N 2cefadroxil cap 02100010000105 021000100001 Y 1cefadroxil susp 02100010001910 021000100019 Y 1cefadroxil susp 02100010001915 021000100019 Y 1cefadroxil tab 02100010000305 021000100003 Y 1cefazolin inj 02100015102110 021000151021 Y M PA_BvDcefazolin inj 02100015102115 021000151021 Y M PA_BvDcefazolin inj 02100015102125 021000151021 Y M PA_BvDCEFAZOLIN INJ 02100015102140 021000151021 N M PA_BvDcefazolin inj 02100015102140 021000151021 Y M PA_BvDCEFAZOLIN INJ 02100015112010 021000151120 N M PA_BvDCEFAZOLIN INJ 02100015112030 021000151120 N M PA_BvDcefdinir cap 02300040000120 023000400001 Y 2cefdinir susp 02300040001920 023000400019 Y 2cefdinir susp 02300040001930 023000400019 Y 2cefepime inj 02400040102110 024000401021 Y M PA_BvDcefepime inj 02400040102120 024000401021 Y M PA_BvDCEFEPIME/DEXTROSE INJ 02400040122110 024000401221 N M PA_BvDCEFEPIME/DEXTROSE INJ 02400040122120 024000401221 N M PA_BvDcefixime susp 02300060001910 023000600019 Y 2cefixime susp 02300060001920 023000600019 Y 2CEFOL TAB 781330000003 O 3* OTCcefotaxime inj 02300075102103 023000751021 Y M PA_BvDcefotaxime inj 02300075102110 023000751021 Y M PA_BvDcefotaxime inj 02300075102115 023000751021 Y M PA_BvDCEFOTAXIME INJ 1GM 02300075102105 023000751021 N M PA_BvDcefotetan inj 02200057102110 022000571021 Y M PA_BvDcefotetan inj 02200057102120 022000571021 Y M PA_BvDCEFOTETAN INJ 02200057102150 022000571021 N M PA_BvDcefoxitin inj 02200060102105 022000601021 Y M PA_BvDcefoxitin inj 02200060102110 022000601021 Y M PA_BvDcefoxitin inj 02200060102115 022000601021 Y M PA_BvDCEFOXITIN INJ 02200060142110 022000601421 N M PA_BvDCEFOXITIN INJ 02200060142120 022000601421 N M PA_BvDcefpodoxime proxetil susp 02300065101920 023000651019 Y 2cefpodoxime proxetil susp 02300065101930 023000651019 Y 2cefpodoxime proxetil tab 02300065100320 023000651003 Y 2cefpodoxime proxetil tab 02300065100330 023000651003 Y 2



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITcefprozil susp 02200062001910 022000620019 Y 2cefprozil susp 02200062001920 022000620019 Y 2cefprozil tab 02200062000320 022000620003 Y 2cefprozil tab 02200062000330 022000620003 Y 2ceftazidime inj 02300080002110 023000800021 Y M PA_BvDceftazidime inj 02300080002115 023000800021 Y M PA_BvDceftazidime inj 02300080002117 023000800021 Y M PA_BvDceftazidime inj 02300080002120 023000800021 Y M PA_BvDCEFTAZIDIME INJ 02300080142110 023000801421 N M PA_BvDCEFTAZIDIME INJ 02300080142120 023000801421 N M PA_BvDCEFTIN SUSP 02200065051910 022000650519 N 3CEFTIN SUSP 02200065051920 022000650519 N 3CEFTIN TAB 02200065050310 022000650503 O 3CEFTIN TAB 02200065050315 022000650503 O 3ceftriaxone inj 02300090102105 023000901021 Y M PA_BvDceftriaxone inj 02300090102110 023000901021 Y M PA_BvDceftriaxone inj 02300090102120 023000901021 Y M PA_BvDceftriaxone inj 02300090102122 023000901021 Y M PA_BvDceftriaxone inj 02300090102125 023000901021 Y M PA_BvDceftriaxone sodium inj 02300090102115 023000901021 Y M PA_BvDceftriaxone sodium inj 02300090102117 023000901021 Y M PA_BvDCEFTRIAXONE/DEXTROSE INJ 02300090132120 023000901321 N M PA_BvDCEFTRIAXONE/DEXTROSE INJ 02300090132130 023000901321 N M PA_BvDcefuroxime axetil susp 022000650519 Y 1*cefuroxime inj 02200065102105 022000651021 Y M PA_BvDcefuroxime inj 02200065102110 022000651021 Y M PA_BvDcefuroxime inj 02200065102140 022000651021 Y M PA_BvDcefuroxime tab 02200065050310 022000650503 Y 1cefuroxime tab 02200065050315 022000650503 Y 1CELEBREX CAP 66100525000110 661005250001 O 3 QLCELEBREX CAP 66100525000120 661005250001 O 3 QLCELEBREX CAP 66100525000130 661005250001 O 3 QLCELEBREX CAP 66100525000140 661005250001 O 3 QLcelecoxib cap 66100525000110 661005250001 Y 2 QLcelecoxib cap 66100525000120 661005250001 Y 2 QLcelecoxib cap 66100525000130 661005250001 Y 2 QLcelecoxib cap 66100525000140 661005250001 Y 2 QLCELEXA TAB 58160020100310 581600201003 O 3CELEXA TAB 58160020100320 581600201003 O 3CELEXA TAB 58160020100340 581600201003 O 3CELLCEPT CAP 99403030100120 994030301001 O 3 PA_BvD



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITCELLCEPT INJ 99403030202120 994030302021 N M PA_BvDCELLCEPT SUSP 99403030101920 994030301019 O 3 PA_BvDCELLCEPT TAB 99403030100330 994030301003 O 3 PA_BvDCELONTIN CAP 72400020000110 724000200001 N 2CENTANY OINTMENT 90100065104210 901000651042 N 3cephalexin cap 02100020000105 021000200001 Y 1cephalexin cap 02100020000110 021000200001 Y 1cephalexin susp 02100020001910 021000200019 Y 1cephalexin susp 02100020001915 021000200019 Y 1CEPHALEXIN TAB 02100020000310 021000200003 N 1CEPHALEXIN TAB 02100020000315 021000200003 N 1CEREBYX INJ 72200013102024 722000131020 O M PA_BvDCEREBYX INJ 72200013102028 722000131020 O M PA_BvDCEREZYME INJ 82700050002120 827000500021 N M NM PA_BvDCERVARIX INJ 17100065301820 171000653018 N $0 PACERVICAL CAP 974018100062 N $0*CESAMET CAP 50300040000110 503000400001 N 3cesia tab 25992002030320 259920020303 Y $0cetirizine chew tab 415500201005 Y 1* OTCcetirizine soln 5mg/5ml 41550020102010 415500201020 Y 2cetirizine syrup 415500201020 Y 1* OTCcetirizine tab 415500201003 Y 1* OTCcetirizine/pseudoephedrine tab 439930022774 Y 1* OTCcevimeline cap 88501525100120 885015251001 Y 2CHANTIX PAK 62100080206320 621000802063 N $0CHANTIX TAB 62100080200320 621000802003 N $0CHANTIX TAB 62100080200330 621000802003 N $0CHEMET CAP 93100080000120 931000800001 N 2CHENODAL TAB 52100010000305 521000100003 N M NMCHLORAMPHENICOL INJ 16200010202160 162000102021 N M PA_BvDchlordiazepoxide cap 57100020100105 571000201001 Y 1chlordiazepoxide cap 57100020100110 571000201001 Y 1chlordiazepoxide cap 57100020100115 571000201001 Y 1chlordiazepoxide/amitriptyline tab 62992002200310 629920022003 Y 1chlordiazepoxide/amitriptyline tab 62992002200320 629920022003 Y 1chlordiazepoxide/clidinium cap 491099024501 Y 1*chloroquine tab 13000010200305 130000102003 Y 2chloroquine tab 13000010200310 130000102003 Y 2chlorothiazide inj 37600020102105 376000201021 Y M PA_BvDCHLOROTHIAZIDE TAB 37600020000305 376000200003 N 1chlorothiazide tab 37600020000310 376000200003 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITCHLORPROMAZINE INJ 59200015102005 592000151020 N M PA_BvDCHLORPROMAZINE INJ 59200015102015 592000151020 N M PA_BvDchlorpromazine tab 59200015100305 592000151003 Y 1chlorpromazine tab 59200015100310 592000151003 Y 1chlorpromazine tab 59200015100315 592000151003 Y 1chlorpromazine tab 59200015100320 592000151003 Y 1chlorpromazine tab 59200015100325 592000151003 Y 1CHLORPROPAMIDE TAB 27200020000305 272000200003 N 1CHLORPROPAMIDE TAB 27200020000310 272000200003 N 1CHLORTHALIDONE TAB 100MG 376000250003 N 1*chlorthalidone tab 25mg 37600025000305 376000250003 Y 1CHLORTHALIDONE TAB 25MG, 50MG 37600025000305 376000250003 N 1CHLORTHALIDONE TAB 25MG, 50MG 37600025000310 376000250003 N 1chlorzoxazone tab 75100040000310 751000400003 Y 1CHOLBAM CAP 52700025000120 527000250001 N 4 ESP NM PACHOLBAM CAP 52700025000140 527000250001 N 4 ESP NM PAcholestyramine bulk powder 39100010002905 391000100029 Y 1cholestyramine light bulk powder 39100010102905 391000101029 Y 1cholestyramine light powder packets 39100010103005 391000101030 Y 1cholestyramine powder packets 39100010003005 391000100030 Y 1CHOLINE MAGNESIUM TRISALICYLATE TAB 641099022003 N 1*choline magnesium trisalicylate tab 641099022003 Y 1*CIALIS TAB 2.5MG, 5MG 40304080000302 403040800003 N NCCIALIS TAB 2.5MG, 5MG 40304080000305 403040800003 N NCciclopirox cream 90150030103705 901500301037 Y 1ciclopirox gel 90150030004010 901500300040 Y 1ciclopirox shampoo 90150030004510 901500300045 Y 2ciclopirox soln 8% 90150030002020 901500300020 Y 1ciclopirox susp 0.77% 90150030101810 901500301018 Y 1cidofovir inj 12200010002020 122000100020 Y M PA_BvDcilastatin/imipenem inj 16159902402110 161599024021 Y M PA_BvDcilastatin/imipenem inj 16159902402120 161599024021 Y M PA_BvDcilostazol tab 85155516000320 851555160003 Y 1cilostazol tab 85155516000330 851555160003 Y 1CILOXAN OPHTH OINTMENT 86101023104210 861010231042 N 3CILOXAN OPHTH SOLN 86101023102010 861010231020 O 3cimetidine oral soln 49200010102050 492000101020 Y 1cimetidine tab 49200010000305 492000100003 Y 1cimetidine tab 49200010000310 492000100003 Y 1cimetidine tab 49200010000315 492000100003 Y 1cimetidine tab 49200010000320 492000100003 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITCIMZIA KIT 52505020106420 525050201064 N 4 NM PACIMZIA KIT 52505020106440 525050201064 N 4 NM PACINRYZE INJ 85802022002120 858020220021 N M NM PACIPRO D5W IV INJ 05000020112024 050000201120 O M PA_BvDCIPRO D5W IV INJ 05000020112028 050000201120 O M PA_BvDCIPRO HC OTIC SUSP 87991002401820 879910024018 N 3CIPRO SUSP 05000020001920 050000200019 O 3CIPRO SUSP 05000020001930 050000200019 O 3CIPRO TAB 05000020100310 050000201003 O 3CIPRO TAB 05000020100315 050000201003 O 3CIPRO XR TAB 05000020057520 050000200575 O 3CIPRO XR TAB 05000020057540 050000200575 O 3CIPRODEX OTIC SUSP 87991002361820 879910023618 N 2ciprofloxacin ER tab 05000020057520 050000200575 Y 2ciprofloxacin ER tab 05000020057540 050000200575 Y 2ciprofloxacin inj 05000020002024 050000200020 Y M PA_BvDciprofloxacin inj 05000020002026 050000200020 Y M PA_BvDciprofloxacin inj 05000020112024 050000201120 Y M PA_BvDciprofloxacin inj 05000020112028 050000201120 Y M PA_BvDciprofloxacin ophth soln 86101023102010 861010231020 Y 1CIPROFLOXACIN OTIC SOLN 871000121020 M 2*ciprofloxacin susp 05000020001920 050000200019 Y 2ciprofloxacin susp 05000020001930 050000200019 Y 2ciprofloxacin tab 05000020100310 050000201003 Y 1ciprofloxacin tab 05000020100315 050000201003 Y 1ciprofloxacin tab 05000020100320 050000201003 Y 1CIPROFLOXACN INJ 05000020002024 050000200020 N M PA_BvDcisplatin inj 21100020002020 211000200020 Y M PA_BvDcisplatin inj 21100020002025 211000200020 Y M PA_BvDCISPLATIN INJ 21100020002030 211000200020 N M PA_BvDcitalopram oral soln 58160020102020 581600201020 Y 1citalopram tab 58160020100310 581600201003 Y 1citalopram tab 58160020100320 581600201003 Y 1citalopram tab 58160020100340 581600201003 Y 1CITRANATAL HARMONY CAP 78516035000130 785160350001 N 3cladribine inj 21300007002015 213000070020 Y M PA_BvDCLAFORAN INJ 02300075102103 023000751021 O M PA_BvDCLAFORAN INJ 02300075102105 023000751021 O M PA_BvDCLAFORAN INJ 02300075102107 023000751021 N M PA_BvDCLAFORAN INJ 02300075102110 023000751021 O M PA_BvDCLAFORAN INJ 02300075102112 023000751021 N M PA_BvD



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITCLAFORAN INJ 02300075102115 023000751021 O M PA_BvDCLARIFOAM EF FOAM 900599032039 O 3*CLARINEX REDITAB 415500210072 O 3* PACLARINEX SYRUP 415500210012 N 3* PACLARINEX SYRUP 41550021001220 415500210012 N 3CLARINEX TAB 41550021000320 415500210003 O 3CLARINEX-D TAB 439930026274 N 3* PACLARINEX-D TAB 439930026275 N 3* PAclarithromycin ER tab 03500010007520 035000100075 Y 2clarithromycin susp 03500010001910 035000100019 Y 1clarithromycin susp 03500010001920 035000100019 Y 1clarithromycin tab 03500010000310 035000100003 Y 1clarithromycin tab 03500010000320 035000100003 Y 1CLARITIN-D TAB 439930025974 O 2* OTCCLARITIN-D TAB 439930025975 O 2* OTCCLEMASTINE SYRUP 41200020401205 412000204012 N Mclemastine tab 41200020400310 412000204003 Y MCLEOCIN CAP 16220020100105 162200201001 O 3CLEOCIN CAP 16220020100110 162200201001 O 3CLEOCIN CAP 16220020100120 162200201001 O 3CLEOCIN INJ 16220020302031 162200203020 O M PA_BvDCLEOCIN INJ 16220020302032 162200203020 O M PA_BvDCLEOCIN INJ 16220020302033 162200203020 O M PA_BvDCLEOCIN INJ 16220020302034 162200203020 O M PA_BvDCLEOCIN INJ 16220020302036 162200203020 N M PA_BvDCLEOCIN INJ 16220020302036 162200203020 O M PA_BvDCLEOCIN INJ 16220020302038 162200203020 O M PA_BvDCLEOCIN PED ORAL SOLN 16220020222120 162200202221 O 3CLEOCIN PHOSPHATE INJ 16220020302037 162200203020 N M PA_BvDCLEOCIN SUPP 55100018105220 551000181052 N 3CLEOCIN VAGINAL CREAM 55100018103720 551000181037 O 3CLEOCIN/DEXTROSE INJ 16220020312020 162200203120 O M PA_BvDCLEOCIN/DEXTROSE INJ 16220020312030 162200203120 O M PA_BvDCLEOCIN/DEXTROSE INJ 16220020312040 162200203120 O M PA_BvDCLEOCIN-T GEL 90051010104005 900510101040 O 3CLEOCIN-T LOTION 90051010104105 900510101041 O 3CLEOCIN-T PAD 90051010109420 900510101094 O 3CLEOCIN-T SOLN 90051010102005 900510101020 O 3CLIMARA PATCH 24000035008810 240000350088 O 3CLIMARA PATCH 24000035008815 240000350088 O 3CLIMARA PATCH 24000035008820 240000350088 O 3



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITCLIMARA PATCH 24000035008824 240000350088 O 3CLIMARA PATCH 24000035008830 240000350088 O 3CLIMARA PATCH 24000035008840 240000350088 O 3CLIMARA PRO PATCH 24993002588820 249930025888 N 3CLINDACIN KIT 90059902626420 900599026264 N MCLINDAGEL 90051010104005 900510101040 N 3clindamycin cap 16220020100105 162200201001 Y 1clindamycin cap 16220020100110 162200201001 Y 1clindamycin cap 16220020100120 162200201001 Y 1clindamycin foam 90051010103905 900510101039 Y Mclindamycin gel 90051010104005 900510101040 Y 1clindamycin inj 16220020302031 162200203020 Y M PA_BvDclindamycin inj 16220020302032 162200203020 Y M PA_BvDclindamycin inj 16220020302033 162200203020 Y M PA_BvDclindamycin inj 16220020302034 162200203020 Y M PA_BvDclindamycin inj 16220020302036 162200203020 Y M PA_BvDclindamycin inj 16220020302037 162200203020 Y M PA_BvDclindamycin inj 16220020302038 162200203020 Y M PA_BvDclindamycin inj 16220020312020 162200203120 Y M PA_BvDclindamycin inj 16220020312030 162200203120 Y M PA_BvDclindamycin inj 16220020312040 162200203120 Y M PA_BvDclindamycin lotion 90051010104105 900510101041 Y 1clindamycin pad 90051010109420 900510101094 Y 1clindamycin soln 16220020222120 162200202221 Y 2clindamycin soln 90051010102005 900510101020 Y 1clindamycin vaginal cream 55100018103720 551000181037 Y 1clindamycin/benzoyl peroxide gel 90059902194020 900599021940 Y 2clindamycin/benzoyl peroxide gel 90059902594020 900599025940 Y 2clindamycin/tretinoin gel 90059902654020 900599026540 Y 3CLINDESSE VAGINAL CREAM 551000181137 N 3*CLINIMIX E INJ 80302020552017 803020205520 N M PA_BvDCLINIMIX E INJ 80302020552032 803020205520 N M PA_BvDCLINIMIX E INJ 80302020602017 803020206020 N M PA_BvDCLINIMIX E INJ 80302020602032 803020206020 N M PA_BvDCLINIMIX E INJ 80302020652040 803020206520 N M PA_BvDCLINIMIX E INJ 80302020702040 803020207020 N M PA_BvDCLINIMIX E INJ 80302020752032 803020207520 N M PA_BvDCLINIMIX E INJ 80302020752040 803020207520 N M PA_BvDCLINIMIX INJ 80302010202015 803020102020 N M PA_BvDCLINIMIX INJ 80302010202032 803020102020 N M PA_BvDCLINIMIX INJ 80302010272040 803020102720 N M PA_BvD



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITCLINIMIX INJ 80302010302040 803020103020 N M PA_BvDCLINIMIX INJ 80302010352040 803020103520 N M PA_BvDCLINISTIX 941000351061 N 20%* OTCclobetasol E cream 90550025153705 905500251537 Y 1clobetasol foam 90550025103920 905500251039 Y 2clobetasol gel 90550025104010 905500251040 Y 1clobetasol lotion 90550025104110 905500251041 Y 2clobetasol ointment 90550025104205 905500251042 Y 1clobetasol shampoo 90550025104520 905500251045 Y 2clobetasol soln 90550025102005 905500251020 Y 1clobetasol spray 90550025100910 905500251009 Y 2CLOBEX LOTION 90550025104110 905500251041 O 3CLOBEX SHAMPOO 90550025104520 905500251045 O 3CLOBEX SPRAY 90550025100910 905500251009 O 3CLODERM CREAM/CLOCORTOLONE CREAM 90550030103705 905500301037 M 3CLOLAR INJ 21300008002020 213000080020 N M PA_BvDclomipramine cap 58200025100120 582000251001 Y 2clomipramine cap 58200025100130 582000251001 Y 2clomipramine cap 58200025100140 582000251001 Y 2clonazepam ODT 72100010007210 721000100072 Y 2clonazepam ODT 72100010007215 721000100072 Y 2clonazepam ODT 72100010007220 721000100072 Y 2clonazepam ODT 72100010007230 721000100072 Y 2clonazepam ODT 72100010007240 721000100072 Y 2clonazepam tab 72100010000305 721000100003 Y 1clonazepam tab 72100010000310 721000100003 Y 1clonazepam tab 72100010000315 721000100003 Y 1clonidine patch 36201010108810 362010101088 Y 2clonidine patch 36201010108820 362010101088 Y 2clonidine patch 36201010108830 362010101088 Y 2clonidine tab 36201010100305 362010101003 Y 1clonidine tab 36201010100310 362010101003 Y 1clonidine tab 36201010100315 362010101003 Y 1clopidogrel tab 75mg 85158020100320 851580201003 Y 1clorazepate dipotassium tab 57100030100305 571000301003 Y 1clorazepate dipotassium tab 57100030100310 571000301003 Y 1clorazepate dipotassium tab 57100030100320 571000301003 Y 1CLORPRES TAB 36995002200310 369950022003 N MCLORPRES TAB 36995002200320 369950022003 N MCLORPRES TAB 36995002200330 369950022003 N Mclotrimazole cream 90154020003705 901540200037 Y M



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITclotrimazole soln 90154020002005 901540200020 Y Mclotrimazole troche 88100020004805 881000200048 Y 1clotrimazole/betamethasone cream 90159902053710 901599020537 Y 1clotrimazole/betamethasone lotion 90159902054120 901599020541 Y 2clozapine ODT 59152020007220 591520200072 Y 2clozapine ODT 59152020007230 591520200072 Y 2clozapine tab 59152020000320 591520200003 Y 2clozapine tab 59152020000325 591520200003 Y 2clozapine tab 59152020000330 591520200003 Y 2clozapine tab 59152020000340 591520200003 Y 2CLOZARIL TAB 59152020000320 591520200003 O 3CLOZARIL TAB 59152020000330 591520200003 O 3COARTEM TAB 13990002030320 139900020303 N Mcodeine sulfate tab 65100020200305 651000202003 Y 1 QLcodeine sulfate tab 65100020200310 651000202003 Y 1 QLcodeine sulfate tab 65100020200315 651000202003 Y 1 QLCOGENTIN INJ 73100010102005 731000101020 O M PA_BvDCOLAZAL CAP 52500020100120 525000201001 O 3COLCHICINE/COLCRYS TAB 68000020000310 680000200003 M 2COLESTID GRANULE 39100020102705 391000201027 O 3COLESTID GRANULE PACKETS 39100020103010 391000201030 O 3COLESTID TAB 39100020100320 391000201003 O 3colestipol granule 39100020102705 391000201027 Y 2colestipol granule packets 39100020103010 391000201030 Y 2colestipol tab 39100020100320 391000201003 Y 1colistimeth inj 16000015002105 160000150021 Y M PA_BvDCOLY-MYCIN M INJ 16000015002105 160000150021 O M PA_BvDCOLY-MYCIN S OTIC SUSP 87991004201820 879910042018 N 2COLYTE FLAVOR PACK 46992005302140 469920053021 O MCOMBIGAN OPHTH SOLN 86259902152020 862599021520 N 2COMBIPATCH 24993002128720 249930021287 N 3COMBIPATCH 24993002128730 249930021287 N 3COMBIVENT RESPIMAT 44209902013420 442099020134 N 2COMBIVIR TAB 12109902500320 121099025003 O 4 ESP NMCOMETRIQ CAP DOSE PACK 21534013106460 215340131064 N 4 NM PA_NSOCOMETRIQ CAP DOSE PACK 21534013106470 215340131064 N 4 NM PA_NSOCOMETRIQ CAP DOSE PACK 21534013106480 215340131064 N 4 NM PA_NSOCOMMIT LOZENGE 621000100047 O $0* OTC COMPLERA TAB 12109903400320 121099034003 N 4 ESP NMCOMTAN TAB 73153030000320 731530300003 O 3COMVAX INJ 17990002301820 179900023018 N $0



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITCONCERTA TAB 61400020100460 614000201004 M 3CONCERTA TAB 61400020100465 614000201004 M 3CONCERTA TAB 61400020100470 614000201004 M 3CONCERTA TAB 61400020100480 614000201004 M 3CONDYLOX GEL 90750015004020 907500150040 N 3CONDYLOX SOLN 90750015002020 907500150020 O 3CONTRACEPTIVE FILM 553000100082 N $0* OTCCONTRACEPTIVE FOAM 553000100039 N $0* OTCCONTRACEPTIVE GEL 553000100040 M $0* OTCCONTRACEPTIVE GEL 553000100040 N $0* OTCCONTRACEPTIVE GEL 553000100040 O $0* OTCCONTRACEPTIVE GEL 553000100040 Y $0* OTCCONTRACEPTIVE SPONGE 553000100063 N $0* OTCCONTRACEPTIVE SUPP 553000100052 N $0* OTCCOPAXONE 40MG/ML INJ 6240003010E540 6240003010E5 N 4 ESP NM QLCOPAXONE KIT 20MG/ML 6240003010E520 6240003010E5 O 4 ESP NM QLCOPEGUS TAB 12353070000320 123530700003 O 4 NMCORDARONE TAB 35400005000305 354000050003 O 3CORDRAN CREAM 90550065003710 905500650037 O 3CORDRAN LOTION 90550065004105 905500650041 O 3CORDRAN TAPE 90550065004605 905500650046 N 3COREG CR CAP 33300007207010 333000072070 N 3COREG CR CAP 33300007207020 333000072070 N 3COREG CR CAP 33300007207030 333000072070 N 3COREG CR CAP 33300007207050 333000072070 N 3COREG TAB 33300007000305 333000070003 O 3COREG TAB 33300007000310 333000070003 O 3COREG TAB 33300007000320 333000070003 O 3COREG TAB 33300007000330 333000070003 O 3CORGARD TAB 33100010000303 331000100003 O 3CORGARD TAB 33100010000305 331000100003 O 3CORGARD TAB 33100010000310 331000100003 O 3CORLANOR TAB 40700035100320 407000351003 N 3 PACORLANOR TAB 40700035100330 407000351003 N 3 PACORTANE-B AQUEOUS OTIC SOLN 879920031420 N 3*CORTANE-B OTIC SOLN 879920031220 O 3*CORTEF TAB 22100025000303 221000250003 O 1CORTEF TAB 22100025000305 221000250003 O 1CORTEF TAB 22100025000310 221000250003 O 1CORTENEMA ENEMA 89150010005110 891500100051 O 3CORTIFOAM 89150010103905 891500101039 N 3



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITCORTISONE AC TAB 22100015100310 221000151003 N 2CORTISPORIN CREAM 90109903103710 901099031037 N 3CORTISPORIN OINTMENT 90109904104220 901099041042 N 3CORTISPORIN OTIC SOLN 87991003102010 879910031020 O 3CORZIDE TAB 36992002300310 369920023003 O MCORZIDE TAB 36992002300320 369920023003 O MCOSENTYX INJ 9025057500D520 9025057500D5 N 4 ESP NM PACOSENTYX INJ 9025057500E520 9025057500E5 N 4 ESP NM PACOSMEGEN INJ 21200020002105 212000200021 N M NM PA_BvDCOSOPT OPHTH SOLN 86259902202020 862599022020 O 3COSOPT PF OPHTH SOLN 86259902202060 862599022020 N 2COTELLIC TAB 21533530200320 215335302003 N M NM PA_NSOCOUMADIN TAB 83200030200303 832000302003 O 3COUMADIN TAB 83200030200305 832000302003 O 3COUMADIN TAB 83200030200310 832000302003 O 3COUMADIN TAB 83200030200311 832000302003 O 3COUMADIN TAB 83200030200313 832000302003 O 3COUMADIN TAB 83200030200315 832000302003 O 3COUMADIN TAB 83200030200317 832000302003 O 3COUMADIN TAB 83200030200320 832000302003 O 3COUMADIN TAB 83200030200325 832000302003 O 3COZAAR TAB 36150040200320 361500402003 O 3COZAAR TAB 36150040200330 361500402003 O 3COZAAR TAB 36150040200340 361500402003 O 3CREON CAP 51200024006705 512000240067 N 2CREON CAP 51200024006720 512000240067 N 2CREON CAP 51200024006740 512000240067 N 2CREON CAP 51200024006760 512000240067 N 2CREON CAP 51200024006780 512000240067 N 2CRESTOR TAB 39400060100305 394000601003 O 2 QL RXCCRESTOR TAB 39400060100310 394000601003 O 2 QL RXCCRESTOR TAB 39400060100340 394000601003 O 2 QL RXCCRESTOR TAB 20MG 39400060100320 394000601003 O 2 QL RXCCRESYLATE OTIC SOLN 874000350020 N 3*CRINONE GEL 55370060004010 553700600040 N 2 PACRINONE GEL 55370060004020 553700600040 N 2 PACRIXIVAN CAP 12104530200120 121045302001 N 2CRIXIVAN CAP 12104530200140 121045302001 N 2CROMOLYN NEB SOLN 44150010102505 441500101025 N 2 PA_BvDcromolyn sodium ophth soln 86802010102005 868020101020 Y 1cromolyn soln 52160015101320 521600151013 Y 2



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITcryselle tab 25990002900310 259900029003 Y $0CUBICIN INJ 16270030002140 162700300021 O M NM PA_BvDCUPRIMINE CAP 99200030000110 992000300001 N 2CUTIVATE CREAM 90550068103710 905500681037 O 3CUTIVATE LOTION 90550068104120 905500681041 O 2CUVITRU INJ 19100020202062 191000202020 N 4 ESP NM PA_BvDCUVPOSA SOLN 49102030002060 491020300020 N 3cyanocobalamin inj 821000100020 Y 1*cyclafem tab 25990002500320 259900025003 Y $0cyclafem tab 25992002200310 259920022003 Y $0CYCLESSA TAB 25992002030320 259920020303 O 3cyclobenzaprine tab 75100050100303 751000501003 Y 1cyclobenzaprine tab 75100050100305 751000501003 Y 1cyclobenzaprine tab 7.5mg 75100050100304 751000501003 Y 2CYCLOGYL OPHTH SOLN 1% 863500201020 O 3*cyclopentolate ophth soln 863500201020 Y 1*CYCLOPHOSPHAMIDE CAP 21101020000105 211010200001 N 2 PA_BvDCYCLOPHOSPHAMIDE CAP 21101020000110 211010200001 N 2 PA_BvDCYCLOSET TAB 27574020100320 275740201003 N 3cyclosporine cap 99402020000110 994020200001 Y 2 PA_BvDcyclosporine cap 99402020000140 994020200001 Y 2 PA_BvDcyclosporine inj 99402020002005 994020200020 Y M PA_BvDcyclosporine modified cap 99402020300120 994020203001 Y 2 PA_BvDcyclosporine modified cap 99402020300150 994020203001 Y 2 PA_BvDCYCLOSPORINE MODIFIED CAP 50MG 99402020300130 994020203001 O 2 PA_BvDcyclosporine modified soln 99402020302020 994020203020 Y 2 PA_BvDCYKLOKAPRON INJ 84100040002025 841000400020 O M PA_BvDCYMBALTA CAP 58180025106720 581800251067 O 3 QLCYMBALTA CAP 58180025106730 581800251067 O 3 QLCYMBALTA CAP 58180025106750 581800251067 O 3 QLcyproheptadine syrup 41500020101210 415000201012 Y 1cyproheptadine tab 41500020100305 415000201003 Y 1CYRAMZA INJ 21335070002020 213350700020 N M NM PA_NSOCYRAMZA INJ 21335070002040 213350700020 N M NM PA_NSOCYSTAGON CAP 56400030100120 564000301001 N 2CYSTAGON CAP 56400030100140 564000301001 N 2CYSTARAN OPHTH SOLN 86805525102020 868055251020 N 4 ESP NM PA QLcytarabine inj 21300010002010 213000100020 Y M PA_BvDcytarabine inj 21300010002011 213000100020 Y M PA_BvDcytarabine inj 21300010002040 213000100020 Y M PA_BvDCYTARABINE INJ 20 MG/ML 21300010002010 213000100020 N M PA_BvD



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITCYTOMEL TAB 28100020100305 281000201003 O 3CYTOMEL TAB 28100020100310 281000201003 O 3CYTOMEL TAB 28100020100315 281000201003 O 3CYTOTEC TAB 49250030000310 492500300003 O 3CYTOTEC TAB 49250030000320 492500300003 O 3CYTOVENE INJ 12200030102110 122000301021 O M PA_BvDCYTRA-3 SYRUP 562020301012 N 1*D.H.E. INJ 67000030102005 670000301020 O 3 PA_BvDD10W/NACL INJ 79993002202038 799930022020 N M PA_BvDd10w/nacl inj 79993002202040 799930022020 N M PA_BvDd2.5w/nacl inj 79993002202010 799930022020 Y M PA_BvDd5w/nacl inj 79993002202020 799930022020 Y M PA_BvDD5W/NACL INJ 79993002202022 799930022020 N M PA_BvDd5w/nacl inj 79993002202025 799930022020 Y M PA_BvDd5w/nacl inj 79993002202030 799930022020 Y M PA_BvDd5w/nacl inj 79993002202035 799930022020 Y M PA_BvDdacarbazine inj 21700020002110 217000200021 Y M PA_BvDDACOGEN INJ 21300015002120 213000150021 O M NM PA_BvDDAKLINZA TAB 123530251003 N 4* ESP NM PA QLDALIRESP TAB 44450065000320 444500650003 N MDALVANCE INJ 16000021102130 160000211021 N M NM PA_BvDdanazol cap 23100005000105 231000050001 Y 2danazol cap 23100005000110 231000050001 Y 2danazol cap 23100005000115 231000050001 Y 2DANTRIUM CAP 100MG 75200010100115 752000101001 O 2DANTRIUM CAP 25MG, 50MG 75200010100105 752000101001 O 3DANTRIUM CAP 25MG, 50MG 75200010100110 752000101001 O 3dantrolene cap 75200010100105 752000101001 Y 2dantrolene cap 75200010100110 752000101001 Y 2dantrolene sodium cap 100mg 75200010100115 752000101001 Y 2dapsone tab 16300010000310 163000100003 Y 1dapsone tab 16300010000320 163000100003 Y 1DAPTACEL INJ 18990003201825 189900032018 N $0daptomycin inj 16270030002140 162700300021 Y M NM PA_BvDDARAPRIM TAB 13000040000310 130000400003 N 2darifenacin SR tab 54100010207520 541000102075 Y 3 STdarifenacin SR tab 54100010207530 541000102075 Y 3 STDARZALEX INJ 21353027002020 213530270020 N M NM PA_NSOdaunorubicin inj 21200030102210 212000301022 Y M PA_BvDDAUNOXOME INJ 21200030052210 212000300522 N M PA_BvDDAYPRO TAB 66100065000320 661000650003 O 3



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITDAYTRANA PATCH 61400020005910 614000200059 N 3DAYTRANA PATCH 61400020005915 614000200059 N 3DAYTRANA PATCH 61400020005920 614000200059 N 3DAYTRANA PATCH 61400020005930 614000200059 N 3DDAVP INJ 30201010102030 302010101020 O 4 PA_BvDDDAVP NASAL SOLN 30201010112010 302010101120 O 3DDAVP NASAL SPRAY 30201010132010 302010101320 O 3DDAVP TAB 30201010100310 302010101003 O 3DDAVP TAB 30201010100320 302010101003 O 3decitabine inj 21300015002120 213000150021 Y M NM PA_BvDDECON-A ELIXIR 439930022010 N 3*DECONEX DM TAB 439973031074 N 3*DELESTROGEN INJ 24000035201705 240000352017 N M PA_BvDDELESTROGEN INJ 24000035201710 240000352017 O M PA_BvDDELESTROGEN INJ 24000035201715 240000352017 O M PA_BvDDELZICOL CAP 52500030006530 525000300065 N 2DEMADEX TAB 37200080000310 372000800003 O 3DEMADEX TAB 37200080000320 372000800003 O 3DEMADEX TAB 37200080000330 372000800003 O 3DEMADEX TAB 37200080000350 372000800003 O 3demeclocycline tab 04000010100305 040000101003 Y 1demeclocycline tab 04000010100310 040000101003 Y 1DEMEROL INJ 65100045102015 651000451020 O MDEMEROL TAB 100MG 65100045100310 651000451003 O 3 QLDEMEROL TAB 50MG 65100045100305 651000451003 O 3 QLDEMSER CAP 36300025000110 363000250001 N M NMDENAVIR CREAM 90350060003720 903500600037 N 2DEPACON INJ 72500020102020 725000201020 O M PA_BvDdepade tab 93400030100305 934000301003 Y 2DEPAKENE CAP 72500030000105 725000300001 O 3DEPAKENE SYRUP 72500020101205 725000201012 O 3DEPAKOTE DR TAB 72500010100605 725000101006 O 3DEPAKOTE DR TAB 72500010100610 725000101006 O 3DEPAKOTE DR TAB 72500010100615 725000101006 O 3DEPAKOTE ER TAB 72500010107520 725000101075 O 3DEPAKOTE ER TAB 72500010107530 725000101075 O 3DEPAKOTE SPRINKLE CAP 125MG 7250001010H120 7250001010H1 O 3DEPEN TITRA TAB 99200030000305 992000300003 N 2DEPO ESTRADIOL INJ 5MG/ML 24000035101710 240000351017 N M PA_BvDDEPO PROVERA INJ 2515003510E620 2515003510E6 O MDEPO PROVERA INJ 150MG/ML 25150035101820 251500351018 O M



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITDEPO-MEDROL INJ 22100030101805 221000301018 N M PA_BvDDEPO-MEDROL INJ 22100030101810 221000301018 O M PA_BvDDEPO-MEDROL INJ 22100030101815 221000301018 O M PA_BvDDEPO-TESTOSTERONE INJ 23100030102010 231000301020 O 3 PA_BvDDEPO-TESTOSTERONE INJ 23100030102015 231000301020 O 3 PA_BvDDERMA-SMOOTHE/FS SCALP OIL 90550055101712 905500551017 O 3DERMA-SMOOTHE/FS SCALP OIL 90550055101714 905500551017 O 3DERMATOP CREAM 90550083003710 905500830037 O 3DERMATOP OINTMENT 90550083004210 905500830042 O 3DERMOTIC OIL 87300018101720 873000181017 O 3DESCOVY TAB 12109902290320 121099022903 N 4 ESP NMdesipramine tab 58200030100305 582000301003 Y 2desipramine tab 58200030100310 582000301003 Y 2desipramine tab 58200030100315 582000301003 Y 2desipramine tab 58200030100320 582000301003 Y 2desipramine tab 58200030100325 582000301003 Y 2desipramine tab 58200030100330 582000301003 Y 2DESLORATADINE ODT 415500210072 N 3* PAdesloratadine tab 41550021000320 415500210003 Y 2desmopressin inj 30201010102030 302010101020 Y 2 PA_BvDdesmopressin nasal soln 30201010112010 302010101120 Y 2desmopressin nasal spray 30201010122010 302010101220 Y 2desmopressin nasal spray 30201010132010 302010101320 Y 2desmopressin tab 30201010100310 302010101003 Y 2desmopressin tab 30201010100320 302010101003 Y 2DESOGEN TAB 25990002100320 259900021003 O 3DESONATE GEL 90550035004020 905500350040 N Mdesonide cream 90550035003705 905500350037 Y 1desonide lotion 90550035004105 905500350041 Y 1desonide ointment 90550035004205 905500350042 Y 1DESOWEN CREAM 90550035003705 905500350037 O MDESOWEN LOTION 90550035004105 905500350041 O Mdesoximetasone cream 90550040003710 905500400037 Y 1desoximetasone gel 90550040004005 905500400040 Y 1desoximetasone ointment 90550040004205 905500400042 Y 1DESOXYN TAB 61100030100305 611000301003 O 3DESVENLAFAXINE ER TAB 58180020007520 581800200075 N 3 ST ST_NSODESVENLAFAXINE ER TAB 58180020007540 581800200075 N 3 ST ST_NSODESVENLAFAXINE ER TAB 58180020107520 581800201075 N 3 ST ST_NSODESVENLAFAXINE ER TAB 58180020107540 581800201075 N 3 ST ST_NSODETROL LA CAP 54100060207020 541000602070 O 3



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITDETROL LA CAP 54100060207030 541000602070 O 3DETROL TAB 54100060200320 541000602003 O 3DETROL TAB 54100060200330 541000602003 O 3DEXAMETHASONE CONC 22100020001320 221000200013 N 1dexamethasone elixir 22100020001005 221000200010 Y 1DEXAMETHASONE OPHTH SOLN 0.1% 86300010102005 863000101020 N 1dexamethasone ophth soln 0.1% 86300010102005 863000101020 Y 1dexamethasone phosphate inj 22100020202005 221000202020 Y M PA_BvDdexamethasone phosphate inj 22100020202040 221000202020 Y M PA_BvDdexamethasone phosphate inj 22100020202045 221000202020 Y M PA_BvDdexamethasone phosphate inj 22100020202060 221000202020 Y M PA_BvDDEXAMETHASONE SODIUM PHOSPHATE INJ 22100020202010 221000202020 N M PA_BvDdexamethasone soln 221000200020 Y 1*dexamethasone tab 22100020000315 221000200003 Y 1dexamethasone tab 22100020000320 221000200003 Y 1dexamethasone tab 22100020000330 221000200003 Y 1dexamethasone tab 22100020000340 221000200003 Y 1dexamethasone tab 22100020000345 221000200003 Y 1DEXAMETHASONE TAB 1MG, 2MG 22100020000325 221000200003 N 1DEXAMETHASONE TAB 1MG, 2MG 22100020000335 221000200003 N 1DEXEDRINE CAP 61100020107005 611000201070 O 3DEXEDRINE CAP 61100020107010 611000201070 O 3DEXEDRINE CAP 61100020107015 611000201070 O 3DEXILANT CAP 49270020006520 492700200065 N 3 QL STDEXILANT CAP 49270020006530 492700200065 N 3 QL STdexmethylphenidate ER cap 61400016107020 614000161070 Y 2dexmethylphenidate ER cap 61400016107030 614000161070 Y 2dexmethylphenidate ER cap 61400016107035 614000161070 Y 2dexmethylphenidate ER cap 61400016107040 614000161070 Y 2dexmethylphenidate ER cap 61400016107050 614000161070 Y 2dexmethylphenidate ER cap 61400016107060 614000161070 Y 2dexmethylphenidate tab 61400016100320 614000161003 Y 2dexmethylphenidate tab 61400016100330 614000161003 Y 2dexmethylphenidate tab 61400016100340 614000161003 Y 2DEXPAK TAB 1.5MG 2210002000B720 2210002000B7 N 3DEXPAK TAB 1.5MG 2210002000B725 2210002000B7 N 3DEXPAK TAB 1.5MG 2210002000B730 2210002000B7 N 3dexrazoxane inj 21754040002120 217540400021 Y M PA_BvDdexrazoxane inj 21754040002140 217540400021 Y M PA_BvDdextroamphetamine ER cap 61100020107005 611000201070 Y 1dextroamphetamine ER cap 61100020107010 611000201070 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITdextroamphetamine ER cap 61100020107015 611000201070 Y 1dextroamphetamine soln 61100020102020 611000201020 Y 2dextroamphetamine tab 61100020100305 611000201003 Y 1dextroamphetamine tab 61100020100310 611000201003 Y 1dextromethorphan/guaifenesin liquid 439970025209 Y 3* OTCdextrose 5% in lactated ringers 79993002302020 799930023020 Y M PA_BvDdextrose inj 80100020002015 801000200020 Y M PA_BvDdextrose inj 80100020002020 801000200020 Y M PA_BvDDIABETA TAB 27200040000305 272000400003 M 3DIABETA TAB 27200040000310 272000400003 M 3DIABETA TAB 27200040000315 272000400003 M 3DIABETIC METER 972020100062 N NC OTCDIABETIC METER 972020100064 N NC OTCDIABETIC METER 972020110062 N NC OTCDIALYVITE TAB 781370000003 N 1*DIALYVITE/IRON TAB 781355100003 N 1*DIALYVITE/ZINC TAB 781360000003 N 1*DIAMOX SEQUEL CAP 37100010006920 371000100069 O 3DIAPHRAGM 974020000054 N $0*DIAPHRAGM 974020100054 N $0*DIAPHRAGM 974020200064 N $0*DIAPHRAGM 974020400064 N $0*DIAPHRAGM 974020800054 N $0*DIATZ ZN TAB 781375000003 O 3*diazepam intensol conc 57100040001310 571000400013 Y 1DIAZEPAM RECTAL GEL 72100030004030 721000300040 M 3DIAZEPAM RECTAL GEL 72100030004040 721000300040 M 3DIAZEPAM RECTAL GEL 72100030004060 721000300040 M 3DIAZEPAM SOLN 1MG/ML 57100040002001 571000400020 N 1diazepam tab 57100040000305 571000400003 Y 1diazepam tab 57100040000310 571000400003 Y 1diazepam tab 57100040000315 571000400003 Y 1DIBENZYLINE CAP 36300010100105 363000101001 O 3diclofenac DR tab 66100007200610 661000072006 Y 1diclofenac DR tab 66100007200620 661000072006 Y 1diclofenac DR tab 66100007200630 661000072006 Y 1diclofenac gel 90374035304020 903740353040 Y 2diclofenac gel 1% 90210030304020 902100303040 Y 2 QLdiclofenac ophth soln 86805010102010 868050101020 Y 1diclofenac potassium tab 66100007100330 661000071003 Y 1diclofenac soln 1.5% 90210030302025 902100303020 Y 2



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITdiclofenac SR tab 66100007207530 661000072075 Y 1diclofenac/misoprostol tab 66109902200620 661099022006 Y 2diclofenac/misoprostol tab 66109902200630 661099022006 Y 2dicloxacillin cap 01300020100110 013000201001 Y 1dicloxacillin cap 01300020100115 013000201001 Y 1dicyclomine cap 49103010100105 491030101001 Y 1dicyclomine inj 10mg/ml 49103010102005 491030101020 Y Mdicyclomine soln 49103010102050 491030101020 Y 2dicyclomine tab 49103010100305 491030101003 Y 1didanosine cap 12105015006520 121050150065 Y 2didanosine cap 12105015006528 121050150065 Y 2didanosine cap 12105015006535 121050150065 Y 2didanosine cap 12105015006550 121050150065 Y 2DIDANOSINE SOLN 12105015002120 121050150021 N 3DIFFERIN CREAM 90050003003710 900500030037 O 3 PADIFFERIN GEL 0.1% 90050003004010 900500030040 O 3 PADIFFERIN GEL 0.3% 90050003004030 900500030040 O 2 PADIFICID TAB 03530025000320 035300250003 N 2 NM QL STDIFLORASONE CREAM 90550050103705 905500501037 N 2DIFLORASONE DIACETATE OINTMENT 90550050104205 905500501042 N 2diflorasone ointment 90550050104205 905500501042 Y 1DIFLUCAN SUSP 11407015001910 114070150019 O 3DIFLUCAN SUSP 11407015001940 114070150019 O 3DIFLUCAN TAB 11407015000310 114070150003 O 3DIFLUCAN TAB 11407015000320 114070150003 O 3DIFLUCAN TAB 11407015000325 114070150003 O 3DIFLUCAN TAB 11407015000330 114070150003 O 3diflunisal tab 64100050000310 641000500003 Y 1digoxin inj 31200010002010 312000100020 Y Mdigoxin soln 31200010002040 312000100020 Y 1digoxin tab 125mcg 31200010000305 312000100003 Y 1 QLdigoxin tab 250mcg 31200010000310 312000100003 Y 1DIHYDROCODEINE/ASPIRIN/CAFFEINE CAP 65991303100115 659913031001 M M QLdihydroergotamine inj 67000030102005 670000301020 Y 2 PA_BvDDILANTIN CAP 100MG 72200030200110 722000302001 O 3DILANTIN CAP 30MG 72200030200105 722000302001 N 2DILANTIN INFATABS 72200030000505 722000300005 O 3DILANTIN SUSP 72200030001810 722000300018 O 3DILATRATE SR CAP 32100020000205 321000200002 N 3DILAUDID PF INJ 65100035102007 651000351020 O M PA_BvDDILAUDID PF INJ 65100035102027 651000351020 O M PA_BvD



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITDILAUDID PF INJ 65100035102012 651000351020 N M PA_BvDDILAUDID PF INJ 65100035102022 651000351020 N M PA_BvDDILAUDID TAB 2MG 65100035100310 651000351003 O 3 QLDILAUDID TAB 4MG 65100035100320 651000351003 O 3 QLDILAUDID TAB 8MG 65100035100330 651000351003 O 3 QLDILAUDID-5 LIQUID 65100035100920 651000351009 O M QLdiltiazem cap 34000010117060 340000101170 Y 1diltiazem cap 34000010117070 340000101170 Y 1diltiazem CD cap 34000010127020 340000101270 Y 1diltiazem CD cap 34000010127040 340000101270 Y 1diltiazem CD cap 34000010127050 340000101270 Y 1diltiazem ER cap 34000010106910 340000101069 Y 1diltiazem ER cap 34000010106915 340000101069 Y 1diltiazem ER cap 34000010106920 340000101069 Y 1diltiazem ER tab 34000010127530 340000101275 Y 2diltiazem ER tab 34000010127540 340000101275 Y 2diltiazem ER tab 34000010127550 340000101275 Y 2diltiazem ER tab 34000010127560 340000101275 Y 2diltiazem ER tab 34000010127570 340000101275 Y 2diltiazem inj 34000010102025 340000101020 Y M PA_BvDdiltiazem inj 34000010102030 340000101020 Y M PA_BvDdiltiazem inj 34000010102040 340000101020 Y M PA_BvDDILTIAZEM INJ 34000010102140 340000101021 N M PA_BvDdiltiazem tab 34000010100305 340000101003 Y 1diltiazem tab 34000010100310 340000101003 Y 1diltiazem tab 34000010100315 340000101003 Y 1diltiazem tab 34000010100320 340000101003 Y 1diltiazem tab 34000010127060 340000101270 Y 1dilt-XR cap 34000010107020 340000101070 Y 1dilt-XR cap 34000010107030 340000101070 Y 1dilt-XR cap 34000010107040 340000101070 Y 1diltzac cap 34000010117020 340000101170 Y 1diltzac cap 34000010117030 340000101170 Y 1diltzac cap 34000010117040 340000101170 Y 1diltzac cap 34000010117050 340000101170 Y 1DIOVAN HCT TAB 36994002700320 369940027003 O 3DIOVAN HCT TAB 36994002700340 369940027003 O 3DIOVAN HCT TAB 36994002700350 369940027003 O 3DIOVAN HCT TAB 36994002700360 369940027003 O 3DIOVAN HCT TAB 36994002700370 369940027003 O 3DIOVAN TAB 36150080000310 361500800003 O 3



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITDIOVAN TAB 36150080000320 361500800003 O 3DIOVAN TAB 36150080000330 361500800003 O 3DIOVAN TAB 36150080000340 361500800003 O 3DIPENTUM CAP 52500040100120 525000401001 N 3diphenhydramine elixir (rx only) 41200030101010 412000301010 Y Mdiphenhydramine inj 41200030102010 412000301020 Y M PA_BvDdiphenoxylate/atropine liquid 47100010100910 471000101009 Y 1diphenoxylate/atropine tab 47100010100310 471000101003 Y 1DIPHTHERIA/TETANUS VACCINE INJ 18990002101810 189900021018 N $0DIPROLENE AF CREAM 90550020053705 905500200537 O 3DIPROLENE LOTION 90550020054105 905500200541 O 3DIPROLENE OINTMENT 90550020054205 905500200542 O 3dipyridamole tab 85150030000310 851500300003 Y 1dipyridamole tab 85150030000320 851500300003 Y 1dipyridamole tab 85150030000330 851500300003 Y 1disopyramide cap 35100010100105 351000101001 Y 1disopyramide cap 35100010100110 351000101001 Y 1disulfiram tab 62802040000325 628020400003 Y 2disulfiram tab 62802040000350 628020400003 Y 2DITROPAN XL TAB 54100045207520 541000452075 O 3DITROPAN XL TAB 54100045207530 541000452075 O 3DITROPAN XL TAB 54100045207540 541000452075 O 3DIURIL INJ 37600020102105 376000201021 O M PA_BvDDIURIL SUSP 37600020001805 376000200018 N 2divalproex DR tab 72500010100605 725000101006 Y 1divalproex DR tab 72500010100610 725000101006 Y 1divalproex DR tab 72500010100615 725000101006 Y 1divalproex ER tab 72500010107520 725000101075 Y 1divalproex ER tab 72500010107530 725000101075 Y 1divalproex sprinkle cap 125mg 7250001010H120 7250001010H1 Y 1DIVIGEL/ELESTRIN GEL 240000350040 N 3*DOCEFREZ INJ 21500005002120 215000050021 N M NM PA_BvDDOCEFREZ INJ 21500005002140 215000050021 N M NM PA_BvDdocetaxel conc inj 21500005001310 215000050013 Y M NM PA_BvDdocetaxel conc inj 21500005001315 215000050013 Y M NM PA_BvDDOCETAXEL FOR INJ CONC 21500005001310 215000050013 N M NM PA_BvDDOCETAXEL FOR INJ CONC 21500005001315 215000050013 N M NM PA_BvDDOCETAXEL FOR INJ CONC 21500005001316 215000050013 N M NM PA_BvDDOCETAXEL FOR INJ CONC 21500005001317 215000050013 N M NM PA_BvDDOCETAXEL IV SOLN 21500005002030 215000050020 N M PA_BvDDOCETAXEL IV SOLN 21500005002040 215000050020 N M PA_BvD



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITDOCETAXEL IV SOLN 21500005002050 215000050020 N M PA_BvDDOCETAXEL IV SOLN 21500005002060 215000050020 N M PA_BvDDOCETAXEL NON-ALCOHOL FORMULA IV SOLN 21500005002070 215000050020 N M PA_BvDDOCETAXEL NON-ALCOHOL FORMULA IV SOLN 21500005002075 215000050020 N M PA_BvDDOCETAXEL NON-ALCOHOL FORMULA IV SOLN 21500005002080 215000050020 N M PA_BvDdofetilide cap 35400025000110 354000250001 Y 2dofetilide cap 35400025000120 354000250001 Y 2dofetilide cap 35400025000130 354000250001 Y 2DOLOPHINE TAB 65100050100305 651000501003 O 3 QLDOLOPHINE TAB 65100050100310 651000501003 O 3 QLdonatussin liquid 439962021009 Y 3* OTCdonepezil ODT 62051025107210 620510251072 Y 1 QLdonepezil ODT 62051025107220 620510251072 Y 1 QLdonepezil tab 62051025100310 620510251003 Y 1 QLdonepezil tab 62051025100320 620510251003 Y 1 QLdonepezil tab 23mg 62051025100330 620510251003 Y 2 QL STDONNATAL ELIXIR 491099040510 N 3*DONNATAL TAB 491099040503 N 3*DORIBAX INJ 16150020002120 161500200021 N M PA_BvDdorzolamide ophth soln 86802340102020 868023401020 Y 1dorzolamide/timolol ophth soln 86259902202020 862599022020 Y 1DOVONEX CREAM 90250025003710 902500250037 O 3doxazosin tab 36202005100310 362020051003 Y 1doxazosin tab 36202005100320 362020051003 Y 1doxazosin tab 36202005100330 362020051003 Y 1doxazosin tab 36202005100340 362020051003 Y 1doxepin cap 58200040100105 582000401001 Y 1doxepin cap 58200040100110 582000401001 Y 1doxepin cap 58200040100115 582000401001 Y 1doxepin cap 58200040100125 582000401001 Y 1doxepin cap 58200040100130 582000401001 Y 1DOXEPIN CAP 75MG 58200040100120 582000401001 N 1doxepin soln 58200040101305 582000401013 Y 1DOXEPIN/PRUDOXIN/ZONALON CREAM 90220015103710 902200151037 M 2doxercalciferol cap 30905040000105 309050400001 Y 2 PA_BvDdoxercalciferol cap 30905040000110 309050400001 Y 2 PA_BvDdoxercalciferol cap 30905040000120 309050400001 Y 2 PA_BvDdoxercalciferol inj 30905040002020 309050400020 Y M PA_BvDDOXIL INJ 21200040402210 212000404022 O M NM PA_BvDdoxycycline hyclate cap 04000020100105 040000201001 Y 2doxycycline hyclate cap 04000020100110 040000201001 Y 2



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITdoxycycline hyclate DR tab 040000201006 Y 3*doxycycline hyclate inj 04000020102105 040000201021 Y M PA_BvDdoxycycline hyclate tab 04000020100302 040000201003 Y 2doxycycline hyclate tab 04000020100310 040000201003 Y 2doxycycline monohydrate cap 04000020000105 040000200001 Y 2doxycycline monohydrate cap 04000020000110 040000200001 Y 2doxycycline monohydrate tab 04000020000305 040000200003 Y 2doxycycline monohydrate tab 04000020000307 040000200003 Y 2doxycycline monohydrate tab 04000020000310 040000200003 Y 2doxycycline monohydrate tab 150mg 04000020000315 040000200003 Y Mdoxycycline susp 04000020001905 040000200019 Y 1DRISDOL CAP 772020300001 O 3*dronabinol cap 50300030000110 503000300001 Y 2dronabinol cap 50300030000115 503000300001 Y 2dronabinol cap 50300030000120 503000300001 Y 2DROXIA CAP 82803030000120 828030300001 N 2DROXIA CAP 82803030000130 828030300001 N 2DROXIA CAP 82803030000140 828030300001 N 2DRYSOL SOLN 909700100020 N 1*DUAC GEL 90059902594020 900599025940 O 3DUETACT TAB 27997802400320 279978024003 O 3DUETACT TAB 27997802400340 279978024003 O 3DULERA INHALER 44209902903220 442099029032 N 2 QLDULERA INHALER 44209902903240 442099029032 N 2 QLduloxetine cap 58180025106720 581800251067 Y 2 QLduloxetine cap 58180025106730 581800251067 Y 2 QLduloxetine cap 58180025106750 581800251067 Y 2 QLDULOXETINE DR/IRENKA CAP 58180025106740 581800251067 N M QL ST ST_NSODURAGESIC PATCH 65100025008610 651000250086 O 3 QLDURAGESIC PATCH 65100025008620 651000250086 O 3 QLDURAGESIC PATCH 65100025008630 651000250086 O 3 QLDURAGESIC PATCH 65100025008640 651000250086 O 3 QLDURAGESIC PATCH 65100025008650 651000250086 O 3 QLDUREZOL OPHTH EMULSION 86300012001620 863000120016 N 2dutasteride cap 56851020000120 568510200001 Y 2dutasteride/tamsulosin cap 56859902250120 568599022501 Y 2DUTOPROL TAB 36992002207520 369920022075 M 2DUTOPROL TAB 36992002207520 369920022075 N 2DUTOPROL TAB 36992002207530 369920022075 N 2DUTOPROL TAB 36992002207540 369920022075 N 2DYAZIDE CAP 37990002300105 379900023001 O 3



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITDYMISTA NASAL INHALER 42995502151820 429955021518 N 3 PADYRENIUM CAP 37500030000105 375000300001 N 2DYRENIUM CAP 37500030000110 375000300001 N 2EC-NAPROSYN TAB 66100060000610 661000600006 O 3EC-NAPROSYN TAB 66100060000615 661000600006 O 3econazole cream 90154035103705 901540351037 Y 1ED A-HIST LIQUID 439930023009 N 3* OTCEDARBI TAB 36150010200320 361500102003 N 3EDARBI TAB 36150010200330 361500102003 N 3EDARBYCLOR TAB 36994002100320 369940021003 N 3EDARBYCLOR TAB 36994002100340 369940021003 N 3EDECRIN TAB 37200020000305 372000200003 O 2EDEX INJ 403030100021 N NCEDEX INJ 403030100064 N NCEDURANT TAB 12109080100320 121090801003 N 4 ESP NMEFFEXOR XR CAP 58180090107020 581800901070 O 3EFFEXOR XR CAP 58180090107030 581800901070 O 3EFFEXOR XR CAP 58180090107050 581800901070 O 3EFFIENT TAB 85158060100320 851580601003 N 2EFFIENT TAB 85158060100330 851580601003 N 2EFUDEX CREAM 90372030003730 903720300037 O 3ELAPRASE INJ 30906850002020 309068500020 N M NM PA_BvDELAVIL TAB 58200010100310 582000101003 O MELDEPRYL CAP 73300030100120 733000301001 O 3ELECTROLYTE/D5W INJ 79993002352010 799930023520 N M PA_BvDELESTAT OPHTH SOLN 86802028102020 868020281020 O 3ELIDEL CREAM 90784060003720 907840600037 N 2ELIGARD INJ 21405010106415 214050101064 N M PA_BvDELIGARD INJ 21405010156432 214050101564 N M PA_BvDELIGARD INJ 21405010206435 214050102064 N M PA_BvDELIGARD INJ 21405010256445 214050102564 N M PA_BvDELIMITE CREAM 90900035003720 909000350037 O 3ELIPHOS TAB 52800020100320 528000201003 O 3ELIQUIS TAB 83370010000320 833700100003 N 2ELIQUIS TAB 83370010000330 833700100003 N 2ELITEK INJ 21764065002120 217640650021 N M NM PA_BvDELITEK INJ 21764065002140 217640650021 N M NM PA_BvDELIXOPHYLLINE ELIXIR 44300040001010 443000400010 N 2ELLENCE INJ 21200042102030 212000421020 O M PA_BvDELLENCE INJ 21200042102045 212000421020 O M PA_BvDELMIRON CAP 56500060100110 565000601001 N 2



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITELOCON CREAM 90550082103710 905500821037 O 3ELOCON LOTION 90550082102010 905500821020 O 3ELOCON OINTMENT 90550082104210 905500821042 O 3ELOXATIN INJ 21100028002025 211000280020 O M PA_BvDELOXATIN INJ 21100028002030 211000280020 O M PA_BvDEMADINE OPHTH SOLN 86802025102020 868020251020 N 3EMBEDA CAP 65100055700220 651000557002 N 3 QLEMBEDA CAP 65100055700230 651000557002 N 3 QLEMBEDA CAP 65100055700240 651000557002 N 3 QLEMBEDA CAP 65100055700250 651000557002 N 3 QLEMBEDA CAP 65100055700260 651000557002 N 3 QLEMBEDA CAP 65100055700270 651000557002 N 3 QLEMCYT CAP 21403020100105 214030201001 N 2EMEND CAP 50280020000110 502800200001 N 2 PA_BvD QLEMEND CAP 50280020000120 502800200001 N 2 PA_BvD QLEMEND CAP 50280020000130 502800200001 N 2 PA_BvD QLEMEND CAP THERAPY PACK 50280020006320 502800200063 N 2 PA_BvD QLEMLA CREAM 90859902903710 908599029037 O 3EMPLICITI INJ 21353030002120 213530300021 N M NM PA_NSOEMPLICITI INJ 21353030002130 213530300021 N M NM PA_NSOEMSAM PATCH 58100027008520 581000270085 N 3EMSAM PATCH 58100027008530 581000270085 N 3EMSAM PATCH 58100027008540 581000270085 N 3EMTRIVA CAP 12106030000120 121060300001 N 3EMTRIVA SOLN 12106030002010 121060300020 N 3EMVERM CHEW TAB 100MG 15000010000505 150000100005 N M NMENABLEX TAB 54100010207520 541000102075 O 3 STENABLEX TAB 54100010207530 541000102075 O 3 STenalapril tab 36100020100303 361000201003 Y 1enalapril tab 36100020100305 361000201003 Y 1enalapril tab 36100020100310 361000201003 Y 1enalapril tab 36100020100315 361000201003 Y 1enalapril/hydrochlorothiazide tab 36991802350305 369918023503 Y 1enalapril/hydrochlorothiazide tab 36991802350310 369918023503 Y 1ENBREL INJ 66290030002120 662900300021 N 4 ESP NM PAENBREL INJ 6629003000E525 6629003000E5 N 4 ESP NM PAENBREL INJ 6629003000E530 6629003000E5 N 4 ESP NM PAENBREL SURECLICK INJ 6629003000D530 6629003000D5 N 4 ESP NM PAENDODAN TAB 65990002220340 659900022203 O 3 QLENDOMETRIN SUPP 55370060009910 553700600099 N 2 PAENGERIX-B INJ 17100010201827 171000102018 N $0 PA_BvD



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITENGERIX-B INJ 17100010201830 171000102018 N $0 PA_BvDENGERIX-B INJ 17100010202210 171000102022 N $0 PA_BvDENGERIX-B INJ 17100010202230 171000102022 N $0 PA_BvDENJUVIA TAB 24000017000310 240000170003 N 3ENJUVIA TAB 24000017000315 240000170003 N 3ENJUVIA TAB 24000017000320 240000170003 N 3ENJUVIA TAB 24000017000330 240000170003 N 3ENJUVIA TAB 24000017000340 240000170003 N 3enoxaparin inj 83101020102012 831010201020 Y 2 QLenoxaparin inj 83101020102013 831010201020 Y 2 QLenoxaparin inj 83101020102014 831010201020 Y 2 QLenoxaparin inj 83101020102015 831010201020 Y 2 QLenoxaparin inj 83101020102016 831010201020 Y 2 QLenoxaparin inj 83101020102018 831010201020 Y 2 QLenoxaparin inj 83101020102020 831010201020 Y 2 QLenoxaparin inj 83101020102050 831010201020 Y 2 QLentacapone tab 73153030000320 731530300003 Y 2entecavir tab 12352030000320 123520300003 Y 2 RXCentecavir tab 12352030000330 123520300003 Y 2 RXCENTOCORT EC CAP 22100012006720 221000120067 O 3 NMENTRE-COUGH LIQUID 439973033209 N 3* OTCENVARSUS ER TAB 99404080007510 994040800075 N M PA_BvDENVARSUS ER TAB 99404080007515 994040800075 N M PA_BvDENVARSUS ER TAB 99404080007520 994040800075 N M PA_BvDEPIDUO (FORTE) GEL 90059902034030 900599020340 N 2 PAEPIDUO GEL 90059902034020 900599020340 N 2 PAepinastine ophth soln 86802028102020 868020281020 Y 2epinephrine inj 4420202020E510 4420202020E5 Y M PA_BvDEPIPEN INJ 49502050002 3890004000D540 3890004000D5 N 2 QLEPIPEN-JR INJ 3890004000D520 3890004000D5 N 2 QLepirubicin inj 21200042102030 212000421020 Y M PA_BvDepirubicin inj 21200042102045 212000421020 Y M PA_BvDEPIVIR HBV SOLN 12352050002010 123520500020 N 3EPIVIR HBV TAB 12352050000315 123520500003 O 4EPIVIR SOLN 12106060002020 121060600020 O 4EPIVIR TAB 12106060000320 121060600003 O 4EPIVIR TAB 12106060000330 121060600003 O 4eplerenone tab 36250030000320 362500300003 Y 2eplerenone tab 36250030000330 362500300003 Y 2EPOGEN INJ 82401020002010 824010200020 M 2 PA_BvDEPOGEN INJ 82401020002015 824010200020 M 2 PA_BvD



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITEPOGEN INJ 82401020002020 824010200020 M 2 PA_BvDEPOGEN INJ 82401020002040 824010200020 M 2 PA_BvDEPOGEN INJ 82401020002050 824010200020 M 2 PA_BvDEPROSARTAN MESYLATE TAB 36150024200330 361500242003 N 2EPZICOM TAB 12109902200340 121099022003 O 4 ESP NMEQUETRO CAP 59400015006910 594000150069 N 2EQUETRO CAP 59400015006920 594000150069 N 2EQUETRO CAP 59400015006930 594000150069 N 2ERAXIS INJ 100MG 11500010002130 115000100021 N M PA_BvDERAXIS INJ 50MG 11500010002120 115000100021 N MERBITUX INJ 21353025002020 213530250020 N M NM PA_BvDERBITUX INJ 21353025002025 213530250020 N M NM PA_BvDergoloid mesylates tab 62000010000310 620000100003 Y MERGOLOID MESYLATES TAB 1MG 62000010000310 620000100003 N MERGOMAR SL TAB 67000020100705 670000201007 N MERIVEDGE CAP 21370070000120 213700700001 N 4 ESP NM PA_NSOERTACZO CREAM 90154070103720 901540701037 N 3ERWINAZE INJ 21250010402125 212500104021 N M NM PA_NSOERYGEL 2% 90051020004010 900510200040 O MERYPED SUSP 03100030301910 031000303019 O 2ERYPED SUSP 03100030301915 031000303019 N 2ERY-TAB TAB 03100005000605 031000050006 N 1ERY-TAB TAB 03100005000610 031000050006 N 1ERY-TAB TAB 03100005000615 031000050006 N 1ERYTHROCIN INJ 03100050502105 031000505021 N M PA_BvDERYTHROMYCIN CAP 031000050067 N 1*erythromycin DR cap 031000050067 Y 1*erythromycin gel 90051020004010 900510200040 Y 1erythromycin ophth ointment 5mg/gm 86101025004210 861010250042 Y 1erythromycin pad 90051020004320 900510200043 Y 1erythromycin soln 90051020002010 900510200020 Y 1erythromycin stearate tab 031000101003 Y 1*erythromycin susp 03100030301910 031000303019 Y 2ERYTHROMYCIN TAB 03100005000305 031000050003 N 3ERYTHROMYCIN TAB 03100005000310 031000050003 N 3erythromycin/benzoyl peroxide gel 90059902104010 900599021040 Y 2ESBRIET CAP 45550060000120 455500600001 N 4 NM PAESCAVITE CHEW TAB 784500000005 N 3*escitalopram soln 58160034102020 581600341020 Y 2escitalopram tab 58160034100310 581600341003 Y 1escitalopram tab 58160034100320 581600341003 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITescitalopram tab 58160034100330 581600341003 Y 1ESOMEPRAZOLE INJ 49270025202120 492700252021 N M PA_BvDesomeprazole inj 49270025202120 492700252021 Y M PA_BvDesomeprazole inj 49270025202140 492700252021 Y M PA_BvDestazolam tab 60201005000310 602010050003 Y 1estazolam tab 60201005000320 602010050003 Y 1esterified estrogens/methyltestosterone tab 249910023003 Y 1*ESTRACE TAB 24000035000303 240000350003 O 3ESTRACE TAB 24000035000305 240000350003 O 3ESTRACE TAB 24000035000310 240000350003 O 3ESTRACE VAGINAL CREAM 55350020003705 553500200037 N 2estradiol patch 24000035008810 240000350088 Y 1estradiol patch 24000035008815 240000350088 Y 1estradiol patch 24000035008820 240000350088 Y 1estradiol patch 24000035008824 240000350088 Y 1estradiol patch 24000035008830 240000350088 Y 1estradiol patch 24000035008840 240000350088 Y 1estradiol tab 24000035000303 240000350003 Y 1estradiol tab 24000035000305 240000350003 Y 1estradiol tab 24000035000310 240000350003 Y 1estradiol twice weekly patch 24000035008705 240000350087 Y 2estradiol twice weekly patch 24000035008710 240000350087 Y 2estradiol twice weekly patch 24000035008720 240000350087 Y 2estradiol twice weekly patch 24000035008730 240000350087 Y 2estradiol twice weekly patch 24000035008750 240000350087 Y 2estradiol valerate inj 24000035201710 240000352017 Y M PA_BvDestradiol valerate inj 24000035201715 240000352017 Y M PA_BvDESTRING 55350020009020 553500200090 N 2ESTROPIPATE TAB 24000055000305 240000550003 N 1estropipate tab 24000055000305 240000550003 Y 1ESTROPIPATE TAB 24000055000310 240000550003 N 1estropipate tab 24000055000310 240000550003 Y 1ESTROPIPATE TAB 24000055000315 240000550003 N 1ESTROSTEP FE TAB 25992003300340 259920033003 O 3eszopiclone tab 60204035000320 602040350003 Y 1 QLeszopiclone tab 60204035000330 602040350003 Y 1 QLeszopiclone tab 60204035000340 602040350003 Y 1 QLethacrynic acid tab 37200020000305 372000200003 Y 2ethambutol tab 09000040100305 090000401003 Y 2ethambutol tab 09000040100310 090000401003 Y 2ethosuximide cap 72400010000105 724000100001 Y 2



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITethosuximide soln 72400010002005 724000100020 Y 1ETHYOL INJ 21758010102120 217580101021 O M PA_BvDetidronate disodium tab 30042040100305 300420401003 Y 2ETIDRONATE DISODIUM TAB 400MG 30042040100310 300420401003 N 2etodolac cap 66100008000120 661000080001 Y 1etodolac cap 66100008000130 661000080001 Y 1etodolac ER tab 66100008007520 661000080075 Y 2etodolac ER tab 66100008007530 661000080075 Y 2etodolac ER tab 66100008007540 661000080075 Y 2etodolac tab 66100008000310 661000080003 Y 1etodolac tab 66100008000320 661000080003 Y 1ETOPOPHOSPHATE INJ 21500010602120 215000106021 N M PA_BvDetoposide cap 215000100001 Y 4* ESPetoposide inj 21500010002025 215000100020 Y M PA_BvDetoposide inj 21500010002030 215000100020 Y M PA_BvDetoposide inj 21500010002040 215000100020 Y M PA_BvDEURAX CREAM 90900010003705 909000100037 N 2EURAX LOTION 90900010004105 909000100041 N 3EVAMIST SPRAY 24000035002020 240000350020 N 3EVISTA TAB 30053060100320 300530601003 O 3EVOCLIN FOAM 90051010103905 900510101039 O MEVOTAZ TAB 12109902220330 121099022203 N 4 NMEVOXAC CAP 88501525100120 885015251001 O 3EXACTUSS LIQUID 439973031009 N 3* OTCEXALGO TAB 6510003510A820 6510003510A8 O M QLEXALGO TAB 6510003510A830 6510003510A8 O M QLEXALGO TAB 6510003510A840 6510003510A8 O M QLEXALGO TAB 6510003510A855 6510003510A8 O M QLEXELDERM CREAM 90154075003710 901540750037 N 3EXELDERM SOLN 90154075002010 901540750020 N 3EXELON CAP 62051040200110 620510402001 O 3EXELON CAP 62051040200120 620510402001 O 3EXELON CAP 62051040200130 620510402001 O 3EXELON CAP 62051040200140 620510402001 O 3EXELON PATCH 62051040008520 620510400085 O 2EXELON PATCH 62051040008530 620510400085 O 2EXELON PATCH 62051040008540 620510400085 O 2exemestane tab 21402835000320 214028350003 Y 2EXFORGE HCT TAB 36994503200320 369945032003 O 3EXFORGE HCT TAB 36994503200325 369945032003 O 3EXFORGE HCT TAB 36994503200330 369945032003 O 3



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITEXFORGE HCT TAB 36994503200335 369945032003 O 3EXFORGE HCT TAB 36994503200340 369945032003 O 3EXFORGE TAB 36993002100310 369930021003 O 3 RXCEXFORGE TAB 36993002100320 369930021003 O 3 RXCEXFORGE TAB 36993002100330 369930021003 O 3 RXCEXFORGE TAB 36993002100340 369930021003 O 3 RXCEXJADE TAB (FOR SUSPENSION) 93100025007320 931000250073 N 4 ESP NMEXJADE TAB (FOR SUSPENSION) 93100025007330 931000250073 N 4 ESP NMEXJADE TAB (FOR SUSPENSION) 93100025007340 931000250073 N 4 ESP NMEXTAVIA INJ 62403060506420 624030605064 N 4 ESP NM STEXTINA FOAM 90154045003920 901540450039 O MFABRAZYME INJ 30903610102120 309036101021 N M NM PA_BvDfamciclovir tab 12408040000305 124080400003 Y 2famciclovir tab 12408040000310 124080400003 Y 2famciclovir tab 12408040000320 124080400003 Y 2famotidine inj 49200030002015 492000300020 Y M PA_BvDfamotidine inj 49200030002020 492000300020 Y M PA_BvDfamotidine inj 49200030002030 492000300020 Y M PA_BvDFAMOTIDINE INJ 49200030002040 492000300020 N M PA_BvDFAMOTIDINE INJ 49200030112020 492000301120 N M PA_BvDfamotidine susp 49200030001920 492000300019 Y 2famotidine tab 49200030000320 492000300003 Y 1famotidine tab 49200030000340 492000300003 Y 1FAMVIR TAB 12408040000305 124080400003 O 3FAMVIR TAB 12408040000310 124080400003 O 3FAMVIR TAB 12408040000320 124080400003 O 3FANAPT TAB 59070035000310 590700350003 N 3 PA_NSOFANAPT TAB 59070035000320 590700350003 N 3 PA_NSOFANAPT TAB 59070035000340 590700350003 N 3 PA_NSOFANAPT TAB 59070035000360 590700350003 N 3 PA_NSOFANAPT TAB 59070035000380 590700350003 N 3 PA_NSOFANAPT TAB 59070035000385 590700350003 N 3 PA_NSOFANAPT TAB 59070035000390 590700350003 N 3 PA_NSOFANAPT TAB TITRATION PACK 59070035006320 590700350063 N M PA_NSOFARESTON TAB 21402685100320 214026851003 N 2FARXIGA TAB 27700040200310 277000402003 N 2 QLFARXIGA TAB 27700040200320 277000402003 N 2 QLFARYDAK CAP 21531550100120 215315501001 N 4 ESP NM PA_NSOFARYDAK CAP 21531550100130 215315501001 N 4 ESP NM PA_NSOFARYDAK CAP 21531550100140 215315501001 N 4 ESP NM PA_NSOFASLODEX INJ 21403530002024 214035300020 N M NM PA_BvD



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITFAZACLO ODT 25MG, 100MG 59152020007220 591520200072 O 2FAZACLO ODT 25MG, 100MG 59152020007230 591520200072 O 2FAZACLO/CLOZAPINE ODT 12.5MG, 150MG, 200MG 59152020007210 591520200072 M 2FAZACLO/CLOZAPINE ODT 12.5MG, 150MG, 200MG 59152020007240 591520200072 M 2FAZACLO/CLOZAPINE ODT 12.5MG, 150MG, 200MG 59152020007250 591520200072 M 2felbamate susp 72120020001810 721200200018 Y 2felbamate tab 72120020000310 721200200003 Y 2felbamate tab 72120020000320 721200200003 Y 2FELBATOL SUSP 72120020001810 721200200018 O 3FELBATOL TAB 72120020000310 721200200003 O 3FELBATOL TAB 72120020000320 721200200003 O 3FELDENE CAP 66100070000105 661000700001 O 3FELDENE CAP 66100070000110 661000700001 O 3felodipine ER tab 34000013007505 340000130075 Y 2felodipine ER tab 34000013007510 340000130075 Y 2felodipine ER tab 34000013007520 340000130075 Y 2FEM PH GEL 554099022040 M 3*FEMALE CONDOMS 974015100000 N $0* OTCFEMARA TAB 21402860000320 214028600003 O 3FEMCON FE CHEW TAB 25990003600520 259900036005 O 3FEMHRT LOW DOSE TAB 24993002250305 249930022503 O 3FEMRING 55350020109020 553500201090 N 3FEMRING 55350020109030 553500201090 N 3fenofibrate cap 39200025100107 392000251001 Y 2fenofibrate cap 39200025100115 392000251001 Y 2fenofibrate cap 39200025100130 392000251001 Y 2fenofibrate micronized cap 39200025100104 392000251001 Y 2fenofibrate micronized cap 39200025100114 392000251001 Y 2fenofibrate tab 39200025000308 392000250003 Y 2fenofibrate tab 39200025000310 392000250003 Y 2fenofibrate tab 39200025000312 392000250003 Y 2fenofibrate tab 39200025000322 392000250003 Y 2fenofibrate tab 39200025000323 392000250003 Y 2fenofibrate tab 39200025000325 392000250003 Y 2fenofibric acid DR cap 39200006006520 392000060065 Y NCfenofibric acid DR cap 39200006006540 392000060065 Y NCFENOGLIDE TAB 39200025000308 392000250003 O 3FENOGLIDE TAB 39200025000322 392000250003 O 3FENOPROFEN CAP 66100010100120 661000101001 M 3FENOPROFEN TAB 66100010100305 661000101003 N 1fenoprofen tab 66100010100305 661000101003 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITFENTANYL CITRATE INJ 65100025102032 651000251020 N NCFENTANYL CITRATE INJ 6510002510E215 6510002510E2 N NCfentanyl citrate inj. 65100025102012 651000251020 Y NCfentanyl citrate inj. 65100025102022 651000251020 Y NCfentanyl citrate inj. 65100025102037 651000251020 Y NCfentanyl citrate inj. 65100025102042 651000251020 Y NCFENTANYL CITRATE POWDER 65100025102900 651000251029 N NCfentanyl lozenge 65100025108450 651000251084 Y 2 PA QLfentanyl lozenge 65100025108455 651000251084 Y 2 PA QLfentanyl lozenge 65100025108460 651000251084 Y 2 PA QLfentanyl lozenge 65100025108465 651000251084 Y 2 PA QLfentanyl lozenge 65100025108475 651000251084 Y 2 PA QLfentanyl lozenge 65100025108485 651000251084 Y 2 PA QLfentanyl patch 65100025008610 651000250086 Y 2 QLfentanyl patch 65100025008620 651000250086 Y 2 QLfentanyl patch 65100025008630 651000250086 Y 2 QLfentanyl patch 65100025008640 651000250086 Y 2 QLfentanyl patch 65100025008650 651000250086 Y 2 QLFENTORA TAB 65100025100310 651000251003 N 3 PA QLFENTORA TAB 65100025100320 651000251003 N 3 PA QLFENTORA TAB 65100025100330 651000251003 N 3 PA QLFENTORA TAB 65100025100340 651000251003 N 3 PA QLFENTORA TAB 65100025100350 651000251003 N 3 PA QLferrex forte cap 829920034001 Y 1*ferrex forte cap 829920076001 Y 1*FERRIPROX SOLN 93100028002020 931000280020 N 4 ESP NM PAFERRIPROX TAB 93100028000320 931000280003 N 2 LD NM PAferrous sulfate elixir 823000100010 Y $0* OTCFERROUS SULFATE LIQUID 823000100009 N $0* OTCferrous sulfate soln 823000100020 Y $0* OTCFERROUS SULFATE SYRUP 823000100012 N $0* OTCFETZIMA CAP 58180050107020 581800501070 N 3 QL ST ST_NSOFETZIMA CAP 58180050107040 581800501070 N 3 QL ST ST_NSOFETZIMA CAP 58180050107060 581800501070 N 3 QL ST ST_NSOFETZIMA CAP 58180050107080 581800501070 N 3 QL ST ST_NSOFETZIMA CAP TITRATION PACK 5818005010B620 5818005010B6 N 3 QL ST ST_NSOFEXMID TAB 75100050100304 751000501003 O 3fexofenadine tab 415500241003 Y 3* OTCFIBRICOR TAB 39200024000320 392000240003 M 3FIBRICOR TAB 39200024000340 392000240003 M 3FINACEA FOAM 90060010003920 900600100039 N 2



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITFINACEA GEL 90060010004020 900600100040 N 2finasteride tab 56851030000320 568510300003 Y 1FIRAZYR INJ 85820040102020 858200401020 N M NM PAFIRMAGON INJ 120MG 21405525102130 214055251021 N M NM PA_NSOFIRMAGON INJ 80MG 21405525102120 214055251021 N M PA_NSOFIRST DUKES MOUTHWASH 881099034918 N 3*FIRST MARYS MOUTHWASH 881099046018 N 3*FIRST MOUTHWASH BLM SUSP 883599054018 N 3*FIRST OMEPRAZOLE SUSP 492700600018 N 3*FLAGYL CAP 16000035000107 160000350001 O 3FLAGYL ER TAB 16000035007520 160000350075 N 3FLAGYL TAB 16000035000305 160000350003 O 3FLAGYL TAB 16000035000310 160000350003 O 3FLAREX OPHTH SUSP 86300020101810 863000201018 N 3flavoxate tab 54400025100310 544000251003 Y 2FLEBOGAMMA INJ 19100020102020 191000201020 N M NM PAFLEBOGAMMA INJ 19100020102044 191000201020 N M NM PAFLEBOGAMMA INJ 19100020102068 191000201020 N M NM PAflecainide tab 35300010100303 353000101003 Y 2flecainide tab 35300010100305 353000101003 Y 2flecainide tab 35300010100310 353000101003 Y 2FLECTOR PATCH 1.3% 90210030205920 902100302059 N 3 PA QLFLOMAX CAP 56852070100110 568520701001 O 3FLO-PRED ORAL SUSP 22100040101860 221000401018 N MFLOVENT DISKUS 44400033208010 444000332080 N 1 QLFLOVENT DISKUS 44400033208020 444000332080 N 1 QLFLOVENT DISKUS 44400033208030 444000332080 N 1 QLFLOVENT HFA INHALER 44400033223220 444000332232 N 1 QLFLOVENT HFA INHALER 44400033223230 444000332232 N 1 QLFLOVENT HFA INHALER 44400033223240 444000332232 N 1 QLfluconazole inj 2mg/ml (100ml) 11407015012010 114070150120 Y Mfluconazole susp 11407015001910 114070150019 Y 1fluconazole susp 11407015001940 114070150019 Y 1fluconazole tab 11407015000310 114070150003 Y 1fluconazole tab 11407015000320 114070150003 Y 1fluconazole tab 11407015000325 114070150003 Y 1fluconazole tab 11407015000330 114070150003 Y 1fluconazole/dextrose inj 11407015022020 114070150220 Y M PA_BvDflucytosine cap 11000020000105 110000200001 Y 2flucytosine cap 11000020000110 110000200001 Y 2FLUDARA INJ 21300025102120 213000251021 O M PA_BvD



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITfludarabine inj 21300025102120 213000251021 Y M PA_BvDfludrocortisone tab 22200030100305 222000301003 Y 1FLUMADINE TAB 12500070100320 125000701003 O 3flunisolide nasal spray 42200030002005 422000300020 Y 1 QLfluocinolone acetonide cream 90550055103705 905500551037 Y 1fluocinolone acetonide cream 90550055103710 905500551037 Y 1fluocinolone acetonide oil 90550055101712 905500551017 Y 2fluocinolone acetonide oil 90550055101714 905500551017 Y 2fluocinolone acetonide ointment 90550055104205 905500551042 Y 1fluocinolone acetonide topical soln 90550055102005 905500551020 Y 1fluocinolone otic oil 87300018101720 873000181017 Y 2fluocinonide cream 90550060003705 905500600037 Y 1fluocinonide cream 90550060003710 905500600037 Y 1fluocinonide cream 90550060103705 905500601037 Y 1fluocinonide gel 90550060004005 905500600040 Y 1fluocinonide ointment 90550060004205 905500600042 Y 1fluocinonide soln 90550060002005 905500600020 Y 1FLUOR-A-DAY TAB 793099029005 N $0*fluorometholone ophth susp 86300020001810 863000200018 Y 1FLUOROPLEX CREAM 90372030003710 903720300037 N 2fluorouracil cream 90372030003730 903720300037 Y 2fluorouracil inj 21300030002025 213000300020 Y M PA_BvDfluorouracil inj 21300030002030 213000300020 Y M PA_BvDfluorouracil inj 21300030002035 213000300020 Y M PA_BvDfluorouracil soln 90372030002020 903720300020 Y 2fluorouracil soln 90372030002050 903720300020 Y 2fluoxetine cap 58160040000110 581600400001 Y 1fluoxetine cap 58160040000120 581600400001 Y 1fluoxetine cap 58160040000140 581600400001 Y 1fluoxetine soln 58160040002020 581600400020 Y 1fluoxetine tab 58160040000310 581600400003 Y 1fluoxetine tab 58160040000320 581600400003 Y 1FLUOXETINE TAB 20MG 58160040000320 581600400003 N 2fluphenazine decanoate inj 59200025302005 592000253020 Y M PA_BvDFLUPHENAZINE ELIXIR 59200025101005 592000251010 N MFLUPHENAZINE INJ 59200025102005 592000251020 N M PA_BvDFLUPHENAZINE ORAL CONC 59200025101320 592000251013 N Mfluphenazine tab 59200025100305 592000251003 Y 1fluphenazine tab 59200025100310 592000251003 Y 1fluphenazine tab 59200025100315 592000251003 Y 1fluphenazine tab 59200025100320 592000251003 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITflurandrenolide cream 90550065003710 905500650037 Y 2flurandrenolide lotion 90550065004105 905500650041 Y 3FLURAZEPAM CAP 60201010100105 602010101001 N 1FLURAZEPAM CAP 60201010100110 602010101001 N 1flurbiprofen ophth soln 86805020102010 868050201020 Y 1flurbiprofen tab 66100012000310 661000120003 Y 1flurbiprofen tab 66100012000315 661000120003 Y 1flutamide cap 21402440000110 214024400001 Y 2fluticasone cream 90550068103710 905500681037 Y 1fluticasone nasal spray 42200032301810 422000323018 Y 1 QLfluticasone ointment 90550068104210 905500681042 Y 1fluticasone propionate lotion 90550068104120 905500681041 Y 2fluvastatin cap 39400030100120 394000301001 Y 2fluvastatin cap 39400030100140 394000301001 Y 2fluvastatin ER tab 39400030107530 394000301075 Y 2fluvoxamine ER cap 58160045107020 581600451070 Y 2 ST ST_NSOfluvoxamine ER cap 58160045107030 581600451070 Y 2 ST ST_NSOfluvoxamine tab 58160045100310 581600451003 Y 1fluvoxamine tab 58160045100320 581600451003 Y 1fluvoxamine tab 58160045100330 581600451003 Y 1FML FORTE OPHTH SUSP 86300020001820 863000200018 N 3FML LIQUIFLM OPHTH SUSP 86300020001810 863000200018 O 3FML OPHTH OINTMENT 86300020004205 863000200042 N 3FOCALIN TAB 61400016100320 614000161003 O 3FOCALIN TAB 61400016100330 614000161003 O 3FOCALIN TAB 61400016100340 614000161003 O 3FOCALIN XR CAP 61400016107020 614000161070 O 3FOCALIN XR CAP 61400016107030 614000161070 O 3FOCALIN XR CAP 61400016107035 614000161070 O 3FOCALIN XR CAP 61400016107040 614000161070 O 3FOCALIN XR CAP 61400016107045 614000161070 N 3FOCALIN XR CAP 61400016107050 614000161070 O 3FOCALIN XR CAP 61400016107055 614000161070 N 3FOCALIN XR CAP 61400016107060 614000161070 O 3FOLBEE PLUS CZ TAB 781375000003 N 1*folbee tab 829915032003 Y 1*folic acid tab 822000100003 Y $0* OTCfolic acid tab 1mg 82200010000315 822000100003 Y $0*FOLOTYN INJ 21300054002025 213000540020 N M NM PA_NSOfomepizole inj 93000045002010 930000450020 Y M PA_BvDfondaparinux soln 2.5mg/0.5ml 83103030102020 831030301020 Y 2 PA



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITfondaparinux soln 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml 83103030102035 831030301020 Y 2 NM PAfondaparinux soln 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml 83103030102040 831030301020 Y 2 NM PAfondaparinux soln 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml 83103030102045 831030301020 Y 2 NM PAFORADIL AEROLIZE CAP 44201027100120 442010271001 N 2FORTAMET TAB 27250050007560 272500500075 O NCFORTAMET TAB 27250050007570 272500500075 O NCFORTAZ INJ 02300080002105 023000800021 N M PA_BvDFORTAZ INJ 02300080002112 023000800021 O M PA_BvDFORTAZ INJ 02300080002115 023000800021 O M PA_BvDFORTAZ INJ 02300080002117 023000800021 O M PA_BvDFORTAZ INJ 02300080002120 023000800021 O M PA_BvDFORTEO INJ 30044070002020 300440700020 N 4 ESP NM PAFORTESTA GEL/ TESTOSTERONE GEL 23100030004070 231000300040 M 3 PA QLFORTICAL SPRAY 30043020002080 300430200020 N 2FOSAMAX + D TAB 30042010200370 300420102003 N 3FOSAMAX + D TAB 30042010200380 300420102003 N 3FOSAMAX SOLN 30042010102020 300420101020 N 3FOSAMAX TAB 30042010100370 300420101003 O 3FOSCARNET INJ 24MG/ML 12200020102030 122000201020 N M PA_BvDFOSCARNET INJ 24MG/ML 12200020102040 122000201020 N M PA_BvDfosinopril tab 36100027100310 361000271003 Y 1fosinopril tab 36100027100320 361000271003 Y 1fosinopril tab 36100027100340 361000271003 Y 1fosinopril/hydrochlorothiazide tab 36991802400310 369918024003 Y 1fosinopril/hydrochlorothiazide tab 36991802400320 369918024003 Y 1fosphenytoin inj 72200013102024 722000131020 Y M PA_BvDfosphenytoin inj 72200013102028 722000131020 Y M PA_BvDFOSRENOL CHEW TAB 52800045200540 528000452005 N 2FOSRENOL CHEW TAB 52800045200550 528000452005 N 2FOSRENOL CHEW TAB 52800045200560 528000452005 N 2FOSRENOL POWDER PACK 52800045203030 528000452030 N 2FOSRENOL POWDER PACK 52800045203040 528000452030 N 2FRAGMIN INJ 2500UNIT, 5000UNIT, 10000UNIT, 12500UNIT, 15000UNIT, 18000UNIT 83101010102015 831010101020 M 3 PA_BvDFRAGMIN INJ 2500UNIT, 5000UNIT, 10000UNIT, 12500UNIT, 15000UNIT, 18000UNIT 83101010102015 831010101020 N 3 PA_BvDFRAGMIN INJ 2500UNIT, 5000UNIT, 10000UNIT, 12500UNIT, 15000UNIT, 18000UNIT 83101010102020 831010101020 M 3 PA_BvDFRAGMIN INJ 2500UNIT, 5000UNIT, 10000UNIT, 12500UNIT, 15000UNIT, 18000UNIT 83101010102020 831010101020 N 3 PA_BvD



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITFRAGMIN INJ 2500UNIT, 5000UNIT, 10000UNIT, 12500UNIT, 15000UNIT, 18000UNIT 83101010102040 831010101020 M 3 PA_BvDFRAGMIN INJ 2500UNIT, 5000UNIT, 10000UNIT, 12500UNIT, 15000UNIT, 18000UNIT 83101010102040 831010101020 N 3 PA_BvDFRAGMIN INJ 2500UNIT, 5000UNIT, 10000UNIT, 12500UNIT, 15000UNIT, 18000UNIT 83101010102053 831010101020 M 3 PA_BvDFRAGMIN INJ 2500UNIT, 5000UNIT, 10000UNIT, 12500UNIT, 15000UNIT, 18000UNIT 83101010102053 831010101020 N 3 PA_BvDFRAGMIN INJ 2500UNIT, 5000UNIT, 10000UNIT, 12500UNIT, 15000UNIT, 18000UNIT 83101010102056 831010101020 M 3 PA_BvDFRAGMIN INJ 2500UNIT, 5000UNIT, 10000UNIT, 12500UNIT, 15000UNIT, 18000UNIT 83101010102056 831010101020 N 3 PA_BvDFRAGMIN INJ 2500UNIT, 5000UNIT, 10000UNIT, 12500UNIT, 15000UNIT, 18000UNIT 83101010102060 831010101020 M 3 PA_BvDFRAGMIN INJ 2500UNIT, 5000UNIT, 10000UNIT, 12500UNIT, 15000UNIT, 18000UNIT 83101010102060 831010101020 N 3 PA_BvDFRAGMIN INJ 7500UNIT, 95000UNIT 83101010102045 831010101020 N 3FRAGMIN INJ 7500UNIT, 95000UNIT 83101010102080 831010101020 N 3FREAMINE HBC INJ 80302010102023 803020101020 N M PA_BvDFREESTYLE CALIBRATION LIQUID 99073014002 97202007100900 972020071009 N 20%* OTCFREESTYLE CALIBRATION LIQUID 99073070432 97202007100900 972020071009 N 20%* OTCFREESTYLE FLASH METER 99073017001 97202010006400 972020100064 N NC OTCFREESTYLE FREEDOM LITE METER 99073070914 97202010006410 972020100064 N $0* OTCFREESTYLE INSULINX TEST STRIP 99073071227 94100030006100 941000300061 N 20%* OTCFREESTYLE INSULINX TEST STRIPS 99073071230 94100030006100 941000300061 N NC OTCFREESTYLE KIT INSULINX 99073071143 97202010006410 972020100064 N $0* OTCFREESTYLE LITE METER 99073070804 97202010006200 972020100062 N NC OTCFREESTYLE LITE METER 99073070805 97202010006200 972020100062 N $0* OTCFREESTYLE METER 99073011001 97202010006400 972020100064 N $0* OTCFREESTYLE METER 99073011003 97202010006400 972020100064 N NC OTCFREESTYLE METER 99073011004 97202010006400 972020100064 N NC OTCFREESTYLE METER 99073041001 97202010006400 972020100064 N NC OTCFREESTYLE METER 99073070847 97202010006410 972020100064 N NC OTCFREESTYLE METER 99073070920 97202010006410 972020100064 N NC OTCFREESTYLE TEST STRIP 99073012050 94100030006100 941000300061 N 20%* OTCFREESTYLE TEST STRIP 99073012101 94100030006100 941000300061 N 20%* OTCFREESTYLE TEST STRIP 99073042001 94100030006100 941000300061 N NC OTCFREESTYLE TEST STRIP 99073042050 94100030006100 941000300061 N NC OTCFREESTYLE TEST STRIP 99073070792 94100030006100 941000300061 N NC OTCFREESTYLE TEST STRIP 99073070822 94100030006100 941000300061 N 20%* OTCFREESTYLE TEST STRIP 99073070827 94100030006100 941000300061 N 20%* OTC



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITFREESTYLE TEST STRIP 99073071026 94100030006100 941000300061 N NC OTCFROVA TAB 67406030100320 674060301003 O M QLfrovatriptan tab 67406030100320 674060301003 Y M QLFURADANTIN SUSP 53000050001810 530000500018 O 2furosemide inj 37200030002005 372000300020 Y M PA_BvDFUROSEMIDE SOLN 37200030002045 372000300020 N 1furosemide soln 37200030002050 372000300020 Y 1furosemide tab 37200030000305 372000300003 Y 1furosemide tab 37200030000310 372000300003 Y 1furosemide tab 37200030000315 372000300003 Y 1FUSILEV INJ 21755050102120 217550501021 O M PA_BvDFUZEON INJ 12102530002120 121025300021 N 4 ESP NMFYCOMPA SUSP 72550060001820 725500600018 N M PA_NSOFYCOMPA TAB 72550060000310 725500600003 N M PA_NSOFYCOMPA TAB 72550060000320 725500600003 N M PA_NSOFYCOMPA TAB 72550060000330 725500600003 N M PA_NSOFYCOMPA TAB 72550060000340 725500600003 N M PA_NSOFYCOMPA TAB 72550060000350 725500600003 N M PA_NSOFYCOMPA TAB 72550060000360 725500600003 N M PA_NSOgabapentin cap 72600030000110 726000300001 Y 1gabapentin cap 72600030000130 726000300001 Y 1gabapentin cap 72600030000140 726000300001 Y 1gabapentin soln 72600030002020 726000300020 Y 2gabapentin tab 72600030000330 726000300003 Y 1gabapentin tab 72600030000340 726000300003 Y 1GABITRIL TAB 12MG, 16MG 72170070100315 721700701003 N 2GABITRIL TAB 12MG, 16MG 72170070100320 721700701003 N 2GABITRIL TAB 2MG, 4MG 72170070100302 721700701003 O 3GABITRIL TAB 2MG, 4MG 72170070100305 721700701003 O 3galantamine ER cap 62051030107020 620510301070 Y 2galantamine ER cap 62051030107030 620510301070 Y 2galantamine ER cap 62051030107040 620510301070 Y 2GALANTAMINE SOLN 62051030102020 620510301020 N 2galantamine tab 62051030100320 620510301003 Y 1galantamine tab 62051030100330 620510301003 Y 1galantamine tab 62051030100340 620510301003 Y 1GAMASTAN S/D INJ 19100020002200 191000200022 N M PAGAMMAGARD INJ 19100020102030 191000201020 N M NM PAGAMMAGARD INJ 19100020102034 191000201020 N M NM PAGAMMAGARD INJ 19100020102038 191000201020 N M NM PAGAMMAGARD INJ 19100020102042 191000201020 N M NM PA



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITGAMMAGARD INJ 19100020102076 191000201020 N M NM PAGAMMAGARD INJ 19100020302060 191000203020 N M NM PAGAMMAGARD INJ 19100020302064 191000203020 N M NM PAGAMMAGARD INJ 19100020302068 191000203020 N M NM PAGAMMAGARD INJ 19100020302072 191000203020 N M NM PAGAMMAGARD INJ 19100020302076 191000203020 N M NM PAGAMMAGARD INJ 19100020302080 191000203020 N M NM PAGAMMAGARD INJ 19100020302084 191000203020 N M NM PAganciclovir inj 12200030102110 122000301021 Y M PA_BvDGARAMYCIN OPHTH SOLN 0.3% 86101030002005 861010300020 O MGARDASIL 9 INJ 17100065501800 171000655018 N $0 PAGARDASIL 9 INJ 1710006550E600 1710006550E6 N $0 PAGARDASIL INJ 17100065101820 171000651018 N $0 PAGASTROCROM SOLN 52160015101320 521600151013 O 3gatifloxacin ophth soln 86101029002030 861010290020 Y 2 STGATTEX INJ 52533070006420 525330700064 N M NM PAGAUZE PAD 97303000004309 973030000043 N M OTCgavilyte-C soln 46992005302140 469920053021 Y $0gavilyte-G soln 46992005302130 469920053021 Y $0GAZYVA INJ 21353043002025 213530430020 N M NM PA_BvDGELNIQUE PATCH 10% 54100045204030 541000452040 N 3GELNIQUE PUMP 54100045004020 541000450040 N 3 STgemcitabine inj 21300034102020 213000341020 Y M PA_BvDgemcitabine inj 21300034102040 213000341020 Y M PA_BvDgemcitabine inj 21300034102060 213000341020 Y M PA_BvDgemcitabine inj 21300034102110 213000341021 Y M PA_BvDgemcitabine inj 21300034102140 213000341021 Y M PA_BvDgemfibrozil tab 39200030000310 392000300003 Y 1GEMZAR INJ 21300034102110 213000341021 O M PA_BvDGEMZAR INJ 21300034102140 213000341021 O M PA_BvDGENERESS FE CHEW TAB 25990003600540 259900036005 N 3GENERESS FE CHEW TAB 25990003600540 259900036005 O 3gengraf cap 50mg 99402020300130 994020203001 Y 2 PA_BvDGENOTROPIN/NUTROPIN/OMNITROPE/HUMATROPE INJ 30100020002120 301000200021 N NCGENOTROPIN/NUTROPIN/OMNITROPE/HUMATROPE INJ 30100020002121 301000200021 N NCGENOTROPIN/NUTROPIN/OMNITROPE/HUMATROPE INJ 30100020002123 301000200021 N NCGENOTROPIN/NUTROPIN/OMNITROPE/HUMATROPE INJ 30100020002125 301000200021 N NCGENOTROPIN/NUTROPIN/OMNITROPE/HUMATROPE INJ 30100020002132 301000200021 N NCGENOTROPIN/NUTROPIN/OMNITROPE/HUMATROPE INJ 30100020002134 301000200021 N NCGENOTROPIN/NUTROPIN/OMNITROPE/HUMATROPE INJ 30100020002140 301000200021 N NCGENOTROPIN/NUTROPIN/OMNITROPE/HUMATROPE INJ 30100020002150 301000200021 N NC



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITGENOTROPIN/NUTROPIN/OMNITROPE/HUMATROPE INJ 30100020002166 301000200021 N NCGENOTROPIN/NUTROPIN/OMNITROPE/HUMATROPE INJ 30100020002168 301000200021 N NCGENOTROPIN/NUTROPIN/OMNITROPE/HUMATROPE INJ 30100020002170 301000200021 N NCGENOTROPIN/NUTROPIN/OMNITROPE/HUMATROPE INJ 30100020002172 301000200021 N NCGENOTROPIN/NUTROPIN/OMNITROPE/HUMATROPE INJ 30100020002174 301000200021 N NCGENOTROPIN/NUTROPIN/OMNITROPE/HUMATROPE INJ 30100020002176 301000200021 N NCGENOTROPIN/NUTROPIN/OMNITROPE/HUMATROPE INJ 30100020002178 301000200021 N NCGENOTROPIN/NUTROPIN/OMNITROPE/HUMATROPE INJ 30100020002180 301000200021 N NCGENOTROPIN/NUTROPIN/OMNITROPE/HUMATROPE INJ 30100020002182 301000200021 N NCGENOTROPIN/NUTROPIN/OMNITROPE/HUMATROPE INJ 30100020002184 301000200021 N NCgentak ophth ointment 86101030004205 861010300042 Y 1gentamicin cream 90100050103705 901000501037 Y 1gentamicin inj 07000020102037 070000201020 Y M PA_BvDgentamicin inj 07000020102045 070000201020 Y M PA_BvDgentamicin ointment 90100050104205 901000501042 Y 1gentamicin ophth soln 0.3% 86101030002005 861010300020 Y 1gentamicin/nacl inj 07000020112008 070000201120 Y M PA_BvDGENTAMICIN/NACL INJ 07000020112009 070000201120 N M PA_BvDgentamicin/nacl inj 07000020112015 070000201120 Y M PA_BvDgentamicin/nacl inj 07000020112025 070000201120 Y M PA_BvDGENTAMICIN/NACL INJ 07000020112035 070000201120 N M PA_BvDgentamicin/nacl inj 07000020112045 070000201120 Y M PA_BvDGENVOYA TAB 12109904290315 121099042903 N M NMGEODON CAP 59400085100120 594000851001 O 3GEODON CAP 59400085100130 594000851001 O 3GEODON CAP 59400085100140 594000851001 O 3GEODON CAP 59400085100150 594000851001 O 3GEODON INJ 59400085202120 594000852021 N M PA_BvDgianvi/ocella/loryna tab 25990002150320 259900021503 Y $0GILENYA CAP 62407025100120 624070251001 N 4 ESP NM PA QLGILOTRIF TAB 21534006100320 215340061003 N 4 ESP NM PA_NSO QLGILOTRIF TAB 21534006100330 215340061003 N 4 ESP NM PA_NSO QLGILOTRIF TAB 21534006100340 215340061003 N 4 ESP NM PA_NSO QLGILTUSS LIQUID 439973031109 N 3*GLASSIA INJ 45100010102020 451000101020 N M NM PA_BvDGLEEVEC TAB 21534035100320 215340351003 O 4 ESP NM PA_NSOGLEEVEC TAB 21534035100340 215340351003 O 4 ESP NM PA_NSOGLEOSTINE CAP 21102020000105 211020200001 N 2glimepiride tab 27200027000310 272000270003 Y 1glimepiride tab 27200027000320 272000270003 Y 1glimepiride tab 27200027000340 272000270003 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITglipizide ER tab 27200030007505 272000300075 Y 1glipizide tab 27200030000305 272000300003 Y 1glipizide tab 27200030000310 272000300003 Y 1glipizide XL tab 27200030007510 272000300075 Y 1glipizide XL tab 27200030007520 272000300075 Y 1glipizide/metformin tab 27997002350320 279970023503 Y 1glipizide/metformin tab 27997002350325 279970023503 Y 1glipizide/metformin tab 27997002350340 279970023503 Y 1GLUCAGEN HYPOKIT INJ 27300010152110 273000101521 N 2GLUCAGEN INJ 94200041152110 942000411521 N 2GLUCAGON KIT 27300010106410 273000101064 N 2GLUCOPHAGE TAB 27250050000320 272500500003 O 3GLUCOPHAGE TAB 27250050000340 272500500003 O 3GLUCOPHAGE TAB 27250050000350 272500500003 O 3GLUCOPHAGE XR TAB 27250050007520 272500500075 O 3GLUCOPHAGE XR TAB 27250050007530 272500500075 O 3GLUCOTROL TAB 27200030000305 272000300003 O 3GLUCOTROL TAB 27200030000310 272000300003 O 3GLUCOTROL XL TAB 27200030007505 272000300075 O 3GLUCOTROL XL TAB 27200030007510 272000300075 O 3GLUCOTROL XL TAB 27200030007520 272000300075 O 3GLUCOVANCE TAB 27997002400310 279970024003 O 3GLUCOVANCE TAB 27997002400320 279970024003 O 3GLUCOVANCE TAB 27997002400330 279970024003 O 3glyburide micronized tab 27200040100310 272000401003 Y 1glyburide micronized tab 27200040100320 272000401003 Y 1glyburide micronized tab 27200040100340 272000401003 Y 1glyburide tab 27200040000305 272000400003 Y 1glyburide tab 27200040000310 272000400003 Y 1glyburide tab 27200040000315 272000400003 Y 1glyburide/metformin tab 27997002400310 279970024003 Y 1glyburide/metformin tab 27997002400320 279970024003 Y 1glyburide/metformin tab 27997002400330 279970024003 Y 1glycopyrrolate inj 49102030002012 491020300020 Y M PA_BvDglycopyrrolate inj 49102030002013 491020300020 Y M PA_BvDglycopyrrolate inj 49102030002014 491020300020 Y M PA_BvDglycopyrrolate tab 49102030000310 491020300003 Y 2glycopyrrolate tab 49102030000315 491020300003 Y 2GLYNASE TAB 27200040100310 272000401003 O 3GLYNASE TAB 27200040100320 272000401003 O 3GLYNASE TAB 27200040100340 272000401003 O 3



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITGLYSET TAB 27500050000310 275000500003 O 3GLYSET TAB 27500050000320 275000500003 O 3GLYSET TAB 27500050000340 275000500003 O 3GOLYTELY SOLN 46992005302130 469920053021 O Mgranisetron inj 50250035102001 502500351020 Y M PA_BvDgranisetron inj 50250035102010 502500351020 Y M PA_BvDgranisetron inj 50250035102015 502500351020 Y M PA_BvDgranisetron tab 50250035100310 502500351003 Y 1 PA_BvD QLGRANIX INJ 8240152070E530 8240152070E5 N 4 ESP NM PA_BvDGRANIX INJ 8240152070E540 8240152070E5 N 4 ESP NM PA_BvDGRIFULVIN V TAB 11000030100315 110000301003 O 3griseofulvin micro tab 11000030100315 110000301003 Y 2griseofulvin susp 11000030101805 110000301018 Y 2griseofulvin tab 11000030200305 110000302003 Y 2griseofulvin tab 11000030200315 110000302003 Y 2GRIS-PEG TAB 11000030200305 110000302003 O 3GRIS-PEG TAB 11000030200315 110000302003 O 3guaifenesin/codeine liquid 439970022809 Y 1* OTCguaifenesin/codeine syrup 439970022820 Y 1* OTC QLguanfacine ER tab 61353030107520 613530301075 Y 2guanfacine ER tab 61353030107530 613530301075 Y 2guanfacine ER tab 61353030107540 613530301075 Y 2guanfacine ER tab 61353030107550 613530301075 Y 2guanfacine IR tab 36201025100320 362010251003 Y 1guanfacine IR tab 36201025100330 362010251003 Y 1GUANIDINE TAB 76000030100310 760000301003 N MHALAVEN INJ 21500009202020 215000092020 N M NM PA_BvDHALCION TAB 60201040000310 602010400003 O 3HALDOL DECANOATE INJ 59100010302010 591000103020 O M PA_BvDHALDOL DECANOATE INJ 59100010302020 591000103020 O M PA_BvDHALDOL LACTATE INJ 59100010202005 591000102020 O M PA_BvDhalobetasol cream 90550073103710 905500731037 Y 1halobetasol ointment 90550073104210 905500731042 Y 1HALOG CREAM 90550070003710 905500700037 N 3HALOG OINTMENT 90550070004205 905500700042 N 3haloperidol decanoate inj 59100010302010 591000103020 Y M PA_BvDhaloperidol decanoate inj 59100010302020 591000103020 Y M PA_BvDhaloperidol lactate inj 59100010202005 591000102020 Y M PA_BvDhaloperidol lactate soln 59100010201305 591000102013 Y 1haloperidol tab 59100010100305 591000101003 Y 1haloperidol tab 59100010100310 591000101003 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDIThaloperidol tab 59100010100315 591000101003 Y 1haloperidol tab 59100010100320 591000101003 Y 1haloperidol tab 59100010100325 591000101003 Y 1haloperidol tab 59100010100330 591000101003 Y 1HARVONI TAB 12359902400320 123599024003 N 4 ESP NM PA QLHAVRIX INJ 17100008001830 171000080018 N $0HAVRIX INJ 17100008001840 171000080018 N $0HDC DM SYRUP 439958033012 N 3* OTCHECTOROL CAP 30905040000105 309050400001 O 3 PA_BvDHECTOROL CAP 30905040000110 309050400001 O 3 PA_BvDHECTOROL CAP 30905040000120 309050400001 O 3 PA_BvDHECTOROL INJ 30905040002010 309050400020 N M PA_BvDHECTOROL INJ 30905040002020 309050400020 O M PA_BvDheparin sodium inj 83100020202015 831000202020 Y M PA_BvDheparin sodium inj 83100020202025 831000202020 Y M PA_BvDheparin sodium inj 83100020202034 831000202020 Y M PA_BvDheparin sodium inj 83100020202035 831000202020 Y M PA_BvDheparin sodium inj 83100020202045 831000202020 Y M PA_BvDHEPARIN SODIUM INJ 2000UNIT/ML, 2500UNIT/ML 83100020202018 831000202020 N M PA_BvDHEPARIN SODIUM INJ 2000UNIT/ML, 2500UNIT/ML 83100020202020 831000202020 N M PA_BvDheparin sodium/d5w inj 83100020252005 831000202520 Y M PA_BvDheparin sodium/d5w inj 83100020252010 831000202520 Y M PA_BvDheparin sodium/d5w inj 83100020252020 831000202520 Y M PA_BvDheparin sodium/nacl inj 83100020222005 831000202220 Y M PA_BvDHEPARIN SODIUM/NACL INJ 83100020222015 831000202220 N M PA_BvDHEPARIN SODIUM/NACL INJ 83100020222020 831000202220 N M PA_BvDHEPARIN SODIUM/NACL INJ 83100020222040 831000202220 N M PA_BvDHEPARIN/D5W INJ 83100020252020 831000202520 N M PA_BvDHEPATAMINE SOLN 8% 80302010102025 803020101020 N M PA_BvDHEPSERA TAB 12352015100320 123520151003 O 4HERCEPTIN INJ 21353070002120 213530700021 N M NM PA_BvDHETLIOZ CAP 60250070000130 602500700001 N M NM PAHEXALEN CAP 21100005000110 211000050001 N 2 NMHIBEREX INJ 17200030102122 172000301021 N $0HIPREX TAB 53000020200305 530000202003 O 3HIZENTRA INJ 19100020202050 191000202020 N 4 ESP NM PA_BvDHIZENTRA INJ 19100020202054 191000202020 N 4 ESP NM PA_BvDHIZENTRA INJ 19100020202058 191000202020 N 4 ESP NM PA_BvDHIZENTRA INJ 19100020202065 191000202020 N 4 ESP NM PA_BvDhomatropine ophth soln 863500301020 Y 1*HUMALOG PEN 2710400500E220 2710400500E2 N 3



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITHUMIRA INJ 6627001500F805 6627001500F8 N 4 ESP NM PAHUMIRA INJ 6627001500F810 6627001500F8 N 4 ESP NM PAHUMIRA INJ 6627001500F820 6627001500F8 N 4 ESP NM PAHUMIRA PEN INJ 6627001500F420 6627001500F4 N 4 ESP NM PAHUMULIN MIX 70/30 VIAL 27104090001810 271040900018 N 3 OTCHUMULIN N VIAL 27104020001805 271040200018 N 3 OTCHUMULIN R U-500 INJ 27104010002015 271040100020 N 2HUMULIN R U-500 KWIKPEN 2710401000D250 2710401000D2 N 2HUMULIN R VIAL 27104010002005 271040100020 N 3 OTCHYCAMTIN CAP 215500801001 N 4* ESP PAHYCAMTIN INJ 21550080102120 215500801021 O M NM PA_BvDHYCET SOLN 65991702102015 659917021020 O 3 QLhydralazine inj 36400010102005 364000101020 Y M PA_BvDhydralazine tab 36400010100305 364000101003 Y 1hydralazine tab 36400010100310 364000101003 Y 1hydralazine tab 36400010100315 364000101003 Y 1hydralazine tab 36400010100320 364000101003 Y 1HYDREA CAP 21700030000105 217000300001 O 3hydrochlorothiazide cap 37600040000110 376000400001 Y 1hydrochlorothiazide tab 37600040000303 376000400003 Y 1hydrochlorothiazide tab 37600040000305 376000400003 Y 1hydrochlorothiazide tab 37600040000310 376000400003 Y 1hydrocodone/acetaminophen soln 65991702102015 659917021020 Y 1 QLhydrocodone/acetaminophen soln 65991702102025 659917021020 Y 1 QLHYDROCODONE/ACETAMINOPHEN SOLN 10-325MG 659917021020 N 3*hydrocodone/acetaminophen tab 2.5-325mg 65991702100302 659917021003 Y 2 QLhydrocodone/acetaminophen tab 5-300mg, 7.5-300mg, 10-300mg 65991702100309 659917021003 Y 2 QLhydrocodone/acetaminophen tab 5-300mg, 7.5-300mg, 10-300mg 65991702100322 659917021003 Y 2 QLhydrocodone/acetaminophen tab 5-300mg, 7.5-300mg, 10-300mg 65991702100375 659917021003 Y 2 QLhydrocodone/acetaminophen tab 5-325mg, 7.5-325mg, 10-325mg 65991702100305 659917021003 Y 1 QLhydrocodone/acetaminophen tab 5-325mg, 7.5-325mg, 10-325mg 65991702100356 659917021003 Y 1 QLhydrocodone/acetaminophen tab 5-325mg, 7.5-325mg, 10-325mg 65991702100358 659917021003 Y 1 QLhydrocodone/chlorpheniramine susp 4399520236G1 Y 3* QL

hydrocodone/chlorpheniramine/pseudoephedrine liquid 439953035420 Y 3*



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDIThydrocodone/homatropine syrup 431010100012 Y 1*hydrocodone/ibuprofen tab 65991702500310 659917025003 Y 2 QLhydrocodone/ibuprofen tab 65991702500315 659917025003 Y 2 QLhydrocodone/ibuprofen tab 65991702500320 659917025003 Y 2 QLhydrocodone/ibuprofen tab 65991702500330 659917025003 Y 2 QLhydrocortisone butyrate cream 90550075303705 905500753037 Y 1hydrocortisone butyrate hydrophilic lipo base cream 90550075323705 905500753237 Y 2hydrocortisone butyrate ointment 90550075304205 905500753042 Y 2hydrocortisone butyrate soln 90550075302020 905500753020 Y 1hydrocortisone cream 90550075003720 905500750037 Y 1hydrocortisone cream 90550075003725 905500750037 Y 1hydrocortisone enema 89150010005110 891500100051 Y 2hydrocortisone lotion 905500750041 Y 1*hydrocortisone lotion 1%, 2.5% 90550075004115 905500750041 Y 1hydrocortisone lotion 1%, 2.5% 90550075004120 905500750041 Y 1hydrocortisone ointment 90550075004210 905500750042 Y 1hydrocortisone ointment 90550075004215 905500750042 Y 1hydrocortisone pramoxine cream 899910023137 Y 1*hydrocortisone pramoxine cream 899910023164 Y 1*hydrocortisone supp 891000101052 Y 1*hydrocortisone tab 22100025000303 221000250003 Y 1hydrocortisone tab 22100025000305 221000250003 Y 1hydrocortisone tab 22100025000310 221000250003 Y 1hydrocortisone valerate cream 90550075203705 905500752037 Y 1hydrocortisone valerate ointment 90550075204205 905500752042 Y 1hydromorphone 2mg/ml syr 65100035102010 651000351020 Y Mhydromorphone ER tab 6510003510A820 6510003510A8 Y M QLhydromorphone ER tab 6510003510A830 6510003510A8 Y M QLhydromorphone ER tab 6510003510A840 6510003510A8 Y M QLhydromorphone ER tab 6510003510A855 6510003510A8 Y M QLhydromorphone liquid 65100035100920 651000351009 Y M QLhydromorphone PF inj 65100035102020 651000351020 Y M PA_BvDhydromorphone PF inj 65100035102027 651000351020 Y M PA_BvDHYDROMORPHONE SUPP 651000351052 N 1*hydromorphone tab 2mg 65100035100310 651000351003 Y 1 QLhydromorphone tab 4mg 65100035100320 651000351003 Y 1 QLhydromorphone tab 8mg 65100035100330 651000351003 Y 1 QLhydroxychloroquine tab 13000020100305 130000201003 Y 1HYDROXYPROGESTERONE CAPROATE 250MG/ML INJ 21404007202020 214040072020 N M NM PA_NSOhydroxyurea cap 21700030000105 217000300001 Y 1HYDROXYZINE IM SOLN 57200040102005 572000401020 N M



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDIThydroxyzine inj 57200040102010 572000401020 Y MHYDROXYZINE PAMOATE CAP 100MG 57200040200115 572000402001 N 1hydroxyzine pamoate cap 25mg, 50mg 57200040200105 572000402001 Y 1hydroxyzine pamoate cap 25mg, 50mg 57200040200110 572000402001 Y 1hydroxyzine syrup 57200040101210 572000401012 Y 1hydroxyzine tab 57200040100305 572000401003 Y 1hydroxyzine tab 57200040100310 572000401003 Y 1hydroxyzine tab 57200040100315 572000401003 Y 1hyoscyamine sulfate CR tab 491010301074 Y 1*hyoscyamine sulfate elixir 491010301010 Y 1*hyoscyamine sulfate ODT 491010301072 Y 1*hyoscyamine sulfate SL tab 491010301007 Y 1*hyoscyamine sulfate soln 491010301020 Y 1*hyoscyamine sulfate tab 491010301003 Y 1*HYPER SAL NEB 434000100025 O 3*HYSINGLA ER TAB 6510003010A810 6510003010A8 N 2 QLHYSINGLA ER TAB 6510003010A820 6510003010A8 N 2 QLHYSINGLA ER TAB 6510003010A830 6510003010A8 N 2 QLHYSINGLA ER TAB 6510003010A840 6510003010A8 N 2 QLHYSINGLA ER TAB 6510003010A850 6510003010A8 N 2 QLHYSINGLA ER TAB 6510003010A860 6510003010A8 N 2 QLHYSINGLA ER TAB 6510003010A870 6510003010A8 N 2 QLHYZAAR TAB 36994002450320 369940024503 O 3HYZAAR TAB 36994002450325 369940024503 O 3HYZAAR TAB 36994002450340 369940024503 O 3ibandronate inj 30042048102030 300420481020 Y M PA_BvD STibandronate tab 30042048100360 300420481003 Y 2 QL STIBRANCE CAP 21531060000120 215310600001 N 4 ESP NM PA_NSOIBRANCE CAP 21531060000130 215310600001 N 4 ESP NM PA_NSOIBRANCE CAP 21531060000140 215310600001 N 4 ESP NM PA_NSOIBUDONE TAB 65991702500330 659917025003 O 3 QLibuprofen susp (rx only) 66100020001820 661000200018 Y 1ibuprofen tab (rx only) 66100020000320 661000200003 Y 1ibuprofen tab (rx only) 66100020000330 661000200003 Y 1ibuprofen tab (rx only) 66100020000340 661000200003 Y 1ICLUSIG TAB 21534075100320 215340751003 N 2 ESP NM PA_NSOICLUSIG TAB 21534075100340 215340751003 N 2 ESP NM PA_NSOIDAMYCIN PFS INJ 21200045102035 212000451020 O M PA_BvDidarubicin inj 21200045102025 212000451020 Y M PA_BvDidarubicin inj 21200045102030 212000451020 Y M PA_BvDidarubicin inj 21200045102035 212000451020 Y M PA_BvD



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITIFEX INJ 21101025002110 211010250021 O M PA_BvDIFEX INJ 21101025002130 211010250021 M M PA_BvDifosfamide inj 21101025002025 211010250020 Y M PA_BvDifosfamide inj 21101025002030 211010250020 Y M PA_BvDifosfamide inj 21101025002110 211010250021 Y M PA_BvDILARIS INJ 66460020002120 664600200021 N M NM PAILEVRO OPHTH SUSP 86805050001840 868050500018 N 2imatinib tab 21534035100320 215340351003 Y 4 ESP NM PA_NSOimatinib tab 21534035100340 215340351003 Y 4 ESP NM PA_NSOIMBRUVICA CAP 21534033000120 215340330001 N 4 NM PA_NSO QLIMDUR ER TAB 32100025007520 321000250075 O 3imipramine pamoate cap 58200050200105 582000502001 Y 2imipramine pamoate cap 58200050200110 582000502001 Y 2imipramine pamoate cap 58200050200115 582000502001 Y 2imipramine pamoate cap 58200050200120 582000502001 Y 2imipramine tab 58200050100305 582000501003 Y 1imipramine tab 58200050100310 582000501003 Y 1imipramine tab 58200050100315 582000501003 Y 1imiquimod cream 90773040003720 907730400037 Y 2IMITREX INJ 12MG/ML 67406070102010 674060701020 O 3 QLIMITREX INJ 4MG/0.5ML, 6MG/0.5ML 6740607010D510 6740607010D5 O 3 QLIMITREX INJ 4MG/0.5ML, 6MG/0.5ML 6740607010D520 6740607010D5 O 3 QLIMITREX INJ 4MG/0.5ML, 6MG/0.5ML 6740607010E210 6740607010E2 O 3 QLIMITREX INJ 4MG/0.5ML, 6MG/0.5ML 6740607010E220 6740607010E2 O 3 QLIMITREX TAB 67406070100305 674060701003 O 3 QLIMITREX TAB 67406070100310 674060701003 O 3 QLIMITREX TAB 67406070100320 674060701003 O 3 QLIMOVAX RABIES INJ 17100070002200 171000700022 N $0 PA_BvDIMPLANON/NEXPLANON IMPLANT 253000050023 N $0*IMURAN TAB 99406010000305 994060100003 O 3 PA_BvDINCRELEX INJ 30160045002020 301600450020 N 4 ESP NM PAINCRUSE ELLIPTA INHALER 44100090208030 441000902080 N 2indapamide tab 37600050000303 376000500003 Y 1indapamide tab 37600050000305 376000500003 Y 1INDERAL LA CAP 33100040107025 331000401070 O 3INDERAL LA CAP 33100040107030 331000401070 O 3INDERAL LA CAP 33100040107035 331000401070 O 3INDERAL LA CAP 33100040107040 331000401070 O 3INDOCIN SUPP 66100030005205 661000300052 N 2INDOCIN SUSP 66100030001805 661000300018 N 2indomethacin cap 66100030000105 661000300001 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITindomethacin cap 66100030000110 661000300001 Y 1indomethacin ER cap 66100030000205 661000300002 Y 1INFANRIX INJ 18990003201840 189900032018 N $0INLYTA TAB 21534008000320 215340080003 N 4 ESP NM PA_NSO QLINLYTA TAB 21534008000340 215340080003 N 4 ESP NM PA_NSO QLINNOPRAN XL CAP 33100040127020 331000401270 M 3INNOPRAN XL CAP 33100040127030 331000401270 M 3INSPRA TAB 36250030000320 362500300003 O 3INSPRA TAB 36250030000330 362500300003 O 3INSULIN SYRINGE 97051030906301 970510309063 N 20% OTCINSULIN SYRINGE 97051030906302 970510309063 N 20% OTCINSULIN SYRINGE 97051030906304 970510309063 N 20% OTCINSULIN SYRINGE 97051030906305 970510309063 N 20% OTCINSULIN SYRINGE 97051030906307 970510309063 N 20% OTCINSULIN SYRINGE 97051030906308 970510309063 N 20% OTCINSULIN SYRINGE 97051030906310 970510309063 N 20% OTCINSULIN SYRINGE 97051030906311 970510309063 N 20% OTCINSULIN SYRINGE 97051030906314 970510309063 N 20% OTCINSULIN SYRINGE 97051030906315 970510309063 N 20% OTCINSULIN SYRINGE 97051030906318 970510309063 N 20% OTCINSULIN SYRINGE 97051030906319 970510309063 N 20% OTCINSULIN SYRINGE 97051030906320 970510309063 N 20% OTCINSULIN SYRINGE 97051030906326 970510309063 N 20% OTCINSULIN SYRINGE 97051030906327 970510309063 N 20% OTCINSULIN SYRINGE 97051030906328 970510309063 N 20% OTCINSULIN SYRINGE 97051030906329 970510309063 N 20% OTCINSULIN SYRINGE 97051030906330 970510309063 N 20% OTCINSULIN SYRINGE 97051030906333 970510309063 N 20% OTCINSULIN SYRINGE 97051030906335 970510309063 N 20% OTCINSULIN SYRINGE 97051030906340 970510309063 N 20% OTCINSULIN SYRINGE 97051030906350 970510309063 N 20% OTCINSULIN SYRINGE 97051030906360 970510309063 N 20% OTCINSULIN SYRINGE 97051030906368 970510309063 N 20% OTCINSULIN SYRINGE 97051030906370 970510309063 N 20% OTCINSULIN SYRINGE 97051030906380 970510309063 N 20% OTCINSULIN SYRINGE 97051030906382 970510309063 N 20% OTCINSULIN SYRINGE 97051030906383 970510309063 N 20% OTCINSULIN SYRINGE 97051030906384 970510309063 N 20% OTCINSULIN SYRINGE 97051030906386 970510309063 N 20% OTCINSULIN SYRINGE 97051030906387 970510309063 N 20% OTCINSULIN SYRINGE 97051030906388 970510309063 N 20% OTC



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITINSULIN SYRINGE 97051030906390 970510309063 N 20% OTCINSULIN SYRINGE 97051030906391 970510309063 N 20% OTCINSULIN SYRINGE 97051030906392 970510309063 N 20% OTCINSULIN SYRINGE 97051030906397 970510309063 N 20% OTCINSULIN SYRINGE 97051030906399 970510309063 N 20% OTCINSULIN SYRINGE 97051030956330 970510309563 N 20% OTCINTELENCE TAB 100MG, 200MG 12109035000320 121090350003 N 4 ESP NMINTELENCE TAB 100MG, 200MG 12109035000340 121090350003 N 4 ESP NMINTELENCE TAB 25MG 12109035000310 121090350003 N 4intralipid inj 80200010001620 802000100016 Y M PA_BvDINTRALIPID INJ 80200010001630 802000100016 N M PA_BvDINTRON-A INJ 217000602021 N 4* ESPINTRON-A INJ 21700060202022 217000602020 N 2 PA_BvDINTRON-A INJ 21700060202030 217000602020 N 2 PA_BvDINTRON-A INJ 21700060202130 217000602021 N 2 PA_BvDINTRON-A INJ 18000000UNIT, 50000000UNIT 21700060202135 217000602021 N 4 ESP NM PA_BvDINTRON-A INJ 18000000UNIT, 50000000UNIT 21700060202160 217000602021 N 4 ESP NM PA_BvDINTUNIV TAB 61353030107520 613530301075 O 3INTUNIV TAB 61353030107530 613530301075 O 3INTUNIV TAB 61353030107540 613530301075 O 3INTUNIV TAB 61353030107550 613530301075 O 3INVANZ INJ 16150030102130 161500301021 N M PA_BvDINVANZ INJ 16150030102135 161500301021 N M PA_BvDINVEGA INJ 59070050101837 590700501018 N M PA_NSOINVEGA INJ 59070050101838 590700501018 N M PA_NSOINVEGA INJ 59070050101839 590700501018 N M PA_NSOINVEGA INJ 59070050101845 590700501018 N M PA_NSOINVEGA SUSTENNA INJ 59070050101840 590700501018 N M PA_NSOINVEGA TAB 59070050007505 590700500075 O 3 PA_NSOINVEGA TAB 59070050007510 590700500075 O 3 PA_NSOINVEGA TAB 59070050007520 590700500075 O 3 PA_NSOINVEGA TAB 59070050007530 590700500075 O 3 PA_NSOINVEGA TRINZA INJ 59070050101850 590700501018 N M PA_NSOINVEGA TRINZA INJ 59070050101860 590700501018 N M PA_NSOINVEGA TRINZA INJ 59070050101870 590700501018 N M PA_NSOINVEGA TRINZA INJ 59070050101880 590700501018 N M PA_NSOINVIRASE CAP 12104580200120 121045802001 N MINVIRASE TAB 12104580200320 121045802003 N 4 ESP NMiodoquinol/hydrocortisone cream 901599021537 Y 3*IONOSOL-B/ D5W INJ 79993002622010 799930026220 N M PA_BvDIONOSOL-MB/ D5W INJ 79993002782010 799930027820 N M PA_BvD



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITIOPIDINE OPHTH SOLN 0.5% 86602010102010 866020101020 O 3IOPIDINE OPHTH SOLN 1% 86602010102020 866020101020 N 2IPOL INJ 17100050002250 171000500022 N $0ipratropium nasal spray 42300040102010 423000401020 Y 1ipratropium nasal spray 42300040102020 423000401020 Y 1ipratropium neb 44100030102020 441000301020 Y 1 PA_BvDipratropium/albuterol neb 44209902012015 442099020120 Y 1 PA_BvDirbesartan tab 36150030000310 361500300003 Y 1irbesartan tab 36150030000320 361500300003 Y 1irbesartan tab 36150030000340 361500300003 Y 1irbesartan/hydrochlorothiazide tab 36994002300320 369940023003 Y 1irbesartan/hydrochlorothiazide tab 36994002300340 369940023003 Y 1IRESSA TAB 21534030000320 215340300003 N 4 ESP NM PA_NSOirinotecan inj 40mg/2ml, 100mg/5ml 21550040102025 215500401020 Y M PA_BvDirinotecan inj 40mg/2ml, 100mg/5ml 21550040102030 215500401020 Y M PA_BvDIRINOTECAN INJ 500MG/25ML 21550040102040 215500401020 N M PA_BvDIRON POLYSACCH/THREONIC ACID/B12/FA CAP 829920076001 N 1*IRON SUSP 823000050018 N $0* OTCISENTRESS CHEW TAB 100MG 12103060100540 121030601005 N 2 NMISENTRESS CHEW TAB 25MG 12103060100510 121030601005 N 2ISENTRESS POWDER PACK 12103060103020 121030601030 N 2ISENTRESS TAB 400MG 12103060100320 121030601003 N 4 ESP NMisochron CR tab 32100020000405 321000200004 Y 1ISOLYTE-P/ D5W INJ 79993002832010 799930028320 N M PA_BvDISOLYTE-S INJ 79992001852000 799920018520 N M PA_BvDISONIAZID INJ 09000060002005 090000600020 N MISONIAZID SYRUP 09000060001210 090000600012 N 1isoniazid tab 09000060000305 090000600003 Y 1isoniazid tab 09000060000310 090000600003 Y 1ISOPTO ATROPINE OPHTH SOLN 863500101020 O 3*ISOPTO CARPINE OPHTH SOLN 86501030102015 865010301020 O 3ISOPTO CARPINE OPHTH SOLN 86501030102020 865010301020 O 3ISOPTO CARPINE OPHTH SOLN 86501030102030 865010301020 O 3ISORDIL TAB 32100020000305 321000200003 O 3ISORDIL TAB 32100020000325 321000200003 N 3ISOSORBIDE DINITRATE ER TAB 32100020000405 321000200004 N 1isosorbide dinitrate tab 30mg 32100020000320 321000200003 Y 3isosorbide dinitrate tab 5mg, 10mg, 20mg 32100020000305 321000200003 Y 1isosorbide dinitrate tab 5mg, 10mg, 20mg 32100020000310 321000200003 Y 1isosorbide dinitrate tab 5mg, 10mg, 20mg 32100020000315 321000200003 Y 1isosorbide mononitrate ER tab 32100025007520 321000250075 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITisosorbide mononitrate ER tab 32100025007530 321000250075 Y 1isosorbide mononitrate ER tab 32100025007540 321000250075 Y 1isosorbide mononitrate tab 32100025000310 321000250003 Y 1isosorbide mononitrate tab 32100025000320 321000250003 Y 1isotretinoin cap 90050013000110 900500130001 Y 2isotretinoin cap 90050013000120 900500130001 Y 2isotretinoin cap 90050013000130 900500130001 Y 2isotretinoin cap 90050013000140 900500130001 Y 2isovate cream 90550025103705 905500251037 Y 1isradipine cap 34000015000110 340000150001 Y 1isradipine cap 34000015000120 340000150001 Y 1ISTALOL OPHTH SOLN 86250030102060 862500301020 N 2ISTODAX INJ 21531560002120 215315600021 N M NM PA_NSOitraconazole cap 11407035000120 114070350001 Y 2 PAivermectin tab 15000007000310 150000070003 Y 2IXEMPRA KIT INJ 21500011002140 215000110021 N M NM PA_BvDIXIARO INJ 17100025101800 171000251018 N $0JADENU TAB 93100025000320 931000250003 N 4 ESP NMJADENU TAB 93100025000330 931000250003 N 4 ESP NMJADENU TAB 93100025000340 931000250003 N 4 ESP NMJAKAFI TAB 21537560200310 215375602003 N 4 ESP NM PA_NSO QLJAKAFI TAB 21537560200320 215375602003 N 4 ESP NM PA_NSO QLJAKAFI TAB 21537560200325 215375602003 N 4 ESP NM PA_NSO QLJAKAFI TAB 21537560200330 215375602003 N 4 ESP NM PA_NSO QLJAKAFI TAB 21537560200335 215375602003 N 4 ESP NM PA_NSO QLJALYN CAP 56859902250120 568599022501 O 2JANUMET TAB 27992502700320 279925027003 N 2 QLJANUMET TAB 27992502700340 279925027003 N 2 QLJANUMET XR TAB 27992502707520 279925027075 N 2 QLJANUMET XR TAB 27992502707530 279925027075 N 2 QLJANUMET XR TAB 27992502707540 279925027075 N 2 QLJANUVIA TAB 27550070100320 275500701003 N 2 QL RXCJANUVIA TAB 27550070100330 275500701003 N 2 QL RXCJANUVIA TAB 27550070100340 275500701003 N 2 QL RXCJARDIANCE TAB 27700050000310 277000500003 N 2 QLJARDIANCE TAB 27700050000320 277000500003 N 2 QLJEVTANA INJ 21500003002020 215000030020 N M NM PA_BvDjinteli tab 1mg-5mcg 24993002250310 249930022503 Y 2jolessa tab/amethia LO tab 259930023003 Y 3*junel FE tab 25990003610310 259900036103 Y $0junel FE tab 25990003610320 259900036103 Y $0



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITjunel tab 25990002600310 259900026003 Y $0junel tab 25990002600320 259900026003 Y $0JUXTAPID CAP 39480050200120 394800502001 N M NM PAJUXTAPID CAP 39480050200130 394800502001 N M NM PAJUXTAPID CAP 39480050200140 394800502001 N M NM PAJUXTAPID CAP 39480050200150 394800502001 N M NM PAJUXTAPID CAP 39480050200160 394800502001 N M NM PAJUXTAPID CAP 39480050200170 394800502001 N M NM PAKADCYLA INJ 21355070302120 213550703021 N M NM PA_NSOKADIAN CAP 65100055107010 651000551070 O 3 QLKADIAN CAP 65100055107020 651000551070 O 3 QLKADIAN CAP 65100055107030 651000551070 O 3 QLKADIAN CAP 65100055107035 651000551070 N 3 QLKADIAN CAP 65100055107040 651000551070 O 3 QLKADIAN CAP 65100055107045 651000551070 O 3 QLKADIAN CAP 65100055107050 651000551070 O 3 QLKADIAN CAP 65100055107060 651000551070 O 3 QLKADIAN CAP 65100055107080 651000551070 N 3 QLKALETRA SOLN 12109902552020 121099025520 N 4 ESP NMKALETRA TAB 100-25MG 12109902550310 121099025503 N 3KALETRA TAB 200-50MG 12109902550320 121099025503 N 4 ESP NMKALYDECO PACKET 45302030003020 453020300030 N 4 ESP NM PA QLKALYDECO PACKET 45302030003030 453020300030 N 4 ESP NM PA QLKALYDECO TAB 45302030000320 453020300003 N 4 ESP NM PA QLkariva tab 25991002050320 259910020503 Y $0KAYEXALATE POWDER 99450010002900 994500100029 O 3kcl/d5w inj 79993002102020 799930021020 Y M PA_BvDkcl/d5w inj 79993002102030 799930021020 Y M PA_BvDKCL/D5W/LR INJ 79993003252010 799930032520 N M PA_BvDkcl/d5w/lr inj 79993003252020 799930032520 N M PA_BvDkcl/d5w/nacl inj 79993003102015 799930031020 Y M PA_BvDkcl/d5w/nacl inj 79993003102020 799930031020 Y M PA_BvDKCL/D5W/NACL INJ 79993003102022 799930031020 N M PA_BvDkcl/d5w/nacl inj 79993003102023 799930031020 Y M PA_BvDkcl/d5w/nacl inj 79993003102025 799930031020 Y M PA_BvDkcl/d5w/nacl inj 79993003102027 799930031020 Y M PA_BvDkcl/d5w/nacl inj 79993003102038 799930031020 Y M PA_BvDkcl/d5w/nacl inj 79993003102050 799930031020 Y M PA_BvDKCL/D5W/NACL INJ 79993003102055 799930031020 N M PA_BvDkcl/nacl inj 79992002102015 799920021020 Y M PA_BvDkcl/nacl inj 79992002102020 799920021020 Y M PA_BvD



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITkcl/nacl inj 79992002102030 799920021020 Y M PA_BvDKEFLEX CAP 02100020000105 021000200001 O 3KEFLEX CAP 02100020000110 021000200001 O 3kelnor tab 25990002200310 259900022003 Y $0KENALOG INJ 22100050101805 221000501018 N M PA_BvDKENALOG INJ 22100050101810 221000501018 N M PA_BvDKENALOG SPRAY 90550085103400 905500851034 O 3KEPIVANCE INJ 21765060002120 217650600021 N M NM PA_BvDKEPPRA INJ 72600043002060 726000430020 O M PA_BvDKEPPRA ORAL SOLN 72600043002020 726000430020 O 3KEPPRA TAB 72600043000320 726000430003 O 3KEPPRA TAB 72600043000330 726000430003 O 3KEPPRA TAB 72600043000340 726000430003 O 3KEPPRA TAB 72600043000350 726000430003 O 3KEPPRA XR TAB 72600043007520 726000430075 O 3KEPPRA XR TAB 72600043007530 726000430075 O 3KERAFOAM 30%, 42% 906600800039 N 3*KERALAC CREAM 906600800037 O 3*KERALAC GEL 50% 90660080004050 906600800040 O 3*KERALAC LOTION 906600800041 O 3*KERLONE TAB 33200021100320 332000211003 O 3KETEK TAB 16210070000315 162100700003 N 3KETEK TAB 16210070000320 162100700003 N 3ketoconazole cream 90154045003710 901540450037 Y 1ketoconazole foam 90154045003920 901540450039 Y Mketoconazole shampoo 90154045004510 901540450045 Y 1ketoconazole tab 11404040000310 114040400003 Y 1KETO-DIASTIX 941099024061 N 20%* OTCKETONE BLOOD TEST STRIP 941000380061 N 20%* OTCketoprofen cap 66100035000105 661000350001 Y 1ketoprofen cap 66100035000110 661000350001 Y 1KETOPROFEN ER CAP 66100035007030 661000350070 N 3ketorolac inj 66100037102015 661000371020 Y Mketorolac inj 66100037102030 661000371020 Y Mketorolac inj 66100037102071 661000371020 Y Mketorolac ophth soln 86805035102015 868050351020 Y 1ketorolac ophth soln 86805035102020 868050351020 Y 1ketorolac tab 10mg 66100037100320 661000371003 Y 1 QLketotifen ophth soln 868020401020 Y 1* OTCKEYTRUDA INJ 21353053002030 213530530020 N M NM PA_NSOKEYTRUDA IV SOLN 21353053002120 213530530021 N M NM PA_NSO



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITKHEDEZLA ER TAB 58180020007520 581800200075 M 3 ST ST_NSOKHEDEZLA ER TAB 58180020007540 581800200075 M 3 ST ST_NSOKINERET INJ 6626001000E520 6626001000E5 N 4 ESP NM PAKLARON LOTION 90051036104120 900510361041 O 3KLONOPIN TAB 72100010000305 721000100003 O 3KLONOPIN TAB 72100010000310 721000100003 O 3KLONOPIN TAB 72100010000315 721000100003 O 3KLOR-CON M15 TAB 79700030100435 797000301004 N 2klor-con m20 ER tab 79700030100440 797000301004 Y 1KLOR-CON POWDER PACKET 797000300030 N 3*KLOR-CON POWDER PACKET 797000300030 O 3*KOMBIGLYZE XR TAB 27992502607520 279925026075 N 2 QLKOMBIGLYZE XR TAB 27992502607530 279925026075 N 2 QLKOMBIGLYZE XR TAB 27992502607540 279925026075 N 2 QLKORLYM TAB 27304050000330 273040500003 N 2 NM PAK-PHOS NEUTRAL TAB 796000301003 O 3*K-PHOS TAB 796000100203 N 2*KRISTALOSE PACKET 46600020003010 466000200030 N 3KRISTALOSE PACKET 46600020003020 466000200030 N 3K-TABS CR TAB 79700030000430 797000300004 O 3KUVAN POWDER PACKET 30908565103020 309085651030 N 4 ESP NM PAKUVAN POWDER PACKET 30908565103040 309085651030 N 4 ESP NM PAKUVAN TAB 30908565107320 309085651073 N 4 ESP NM PAKYNAMRO INJ 3950004010E520 3950004010E5 N M NM PAKYPROLIS SOLN 21536025002110 215360250021 N M NM PA_BvDKYPROLIS SOLN 21536025002120 215360250021 N M NM PA_BvDlabetalol inj 33300010102005 333000101020 Y M PA_BvDlabetalol tab 33300010100305 333000101003 Y 1labetalol tab 33300010100310 333000101003 Y 1labetalol tab 33300010100315 333000101003 Y 1LAC-HYDRIN CREAM 90650015003730 906500150037 O 3LAC-HYDRIN LOTION 90650015004130 906500150041 O 3LACRISERT OPHTH INSERT 86203000009900 862030000099 N 2lactated ringers inj 79992001202010 799920012020 Y M PA_BvDlactated ringers irrigation 99750015002000 997500150020 Y M PA_BvDlactulose soln 46600020002010 466000200020 Y 1lactulose soln 52400020002010 524000200020 Y 1LAMICTAL CHEW TAB 72600040000510 726000400005 O 3LAMICTAL CHEW TAB 72600040000520 726000400005 O 3LAMICTAL ODT 72600040007225 726000400072 O 3LAMICTAL ODT 72600040007230 726000400072 O 3



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITLAMICTAL ODT 72600040007240 726000400072 O 3LAMICTAL ODT 72600040007250 726000400072 O 3LAMICTAL ODT KIT 726000400064 O 3*LAMICTAL STARTER KIT 72600040006420 726000400064 N 3LAMICTAL STARTER KIT 72600040006430 726000400064 N 3LAMICTAL STARTER KIT 72600040006435 726000400064 N 3LAMICTAL TAB 72600040000310 726000400003 O 3LAMICTAL TAB 72600040000335 726000400003 O 3LAMICTAL TAB 72600040000340 726000400003 O 3LAMICTAL TAB 72600040000330 726000400003 O 3LAMICTAL XR KIT 726000400064 N 3*LAMICTAL XR KIT 72600040006470 726000400064 N 3LAMICTAL XR KIT 72600040006475 726000400064 N 3LAMICTAL XR KIT 72600040006480 726000400064 N 3LAMICTAL XR TAB 72600040007510 726000400075 O 3LAMICTAL XR TAB 72600040007520 726000400075 O 3LAMICTAL XR TAB 72600040007530 726000400075 O 3LAMICTAL XR TAB 72600040007540 726000400075 O 3LAMICTAL XR TAB 72600040007545 726000400075 O 3LAMICTAL XR TAB 72600040007550 726000400075 O 3LAMISIL GRANULES 11000080103020 110000801030 N MLAMISIL GRANULES 11000080103030 110000801030 N MLAMISIL TAB 11000080100310 110000801003 O 3lamivudine soln 12106060002020 121060600020 Y 2lamivudine tab 12106060000320 121060600003 Y 2lamivudine tab 12106060000330 121060600003 Y 2lamivudine tab 12352050000315 123520500003 Y 2lamivudine/zidovudine tab 12109902500320 121099025003 Y 4 ESP NMlamotrigine chew tab 72600040000510 726000400005 Y 1lamotrigine chew tab 72600040000520 726000400005 Y 1lamotrigine ER tab 72600040007510 726000400075 Y 2lamotrigine ER tab 72600040007520 726000400075 Y 2lamotrigine ER tab 72600040007530 726000400075 Y 2lamotrigine ER tab 72600040007540 726000400075 Y 2lamotrigine ER tab 72600040007545 726000400075 Y 2lamotrigine ER tab 72600040007550 726000400075 Y 2lamotrigine ODT 72600040007225 726000400072 Y 2lamotrigine ODT 72600040007230 726000400072 Y 2lamotrigine ODT 72600040007240 726000400072 Y 2lamotrigine ODT 72600040007250 726000400072 Y 2lamotrigine ODT kit 726000400064 Y 3*



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITlamotrigine tab 72600040000310 726000400003 Y 1lamotrigine tab 72600040000330 726000400003 Y 1lamotrigine tab 72600040000335 726000400003 Y 1lamotrigine tab 72600040000340 726000400003 Y 1LANCET DEVICE 972020270063 N 20%* OTCLANCET KIT 972020300064 N 20%* OTCLANCETS 972020250063 N 20%* OTCLANOXIN INJ 31200010002010 312000100020 O MLANOXIN TAB 125MCG 31200010000305 312000100003 O 3 QLLANOXIN TAB 250MCG 31200010000310 312000100003 O 3lansoprazole cap 49270040006510 492700400065 Y 1lansoprazole cap 49270040006520 492700400065 Y 1LANSOPRAZOLE SUSP 492700400018 N 3*lansoprazole/amoxicillin/clarithromycin pack 49993003206320 499930032063 Y 2LANTUS INJ 27104003002020 271040030020 N 1LANTUS SOLOSTAR INJ 2710400300D220 2710400300D2 N 1LASIX TAB 37200030000305 372000300003 O 3LASIX TAB 37200030000310 372000300003 O 3LASIX TAB 37200030000315 372000300003 O 3LASTACAFT OPHTH SOLN 86802004002020 868020040020 N 3latanoprost ophth soln 86330050002020 863300500020 Y 1 QLLATUDA TAB 59400023100310 594000231003 N 3 PA_NSO QL RXCLATUDA TAB 59400023100320 594000231003 N 3 PA_NSO QL RXCLATUDA TAB 59400023100330 594000231003 N 3 PA_NSO QL RXCLATUDA TAB 59400023100340 594000231003 N 3 PA_NSO QL RXCLATUDA TAB 59400023100350 594000231003 N 3 PA_NSO QL RXCLAZANDA NASAL SPRAY 65100025102050 651000251020 N 3 PA QLLAZANDA NASAL SPRAY 65100025102057 651000251020 N 3 PA QLLAZANDA NASAL SPRAY 65100025102060 651000251020 N 3 PA QLleflunomide tab 66280050000310 662800500003 Y 1leflunomide tab 66280050000320 662800500003 Y 1LENVIMA CAP THERAPY PACK 2153405420B215 2153405420B2 N 4 ESP NM PA_NSOLENVIMA CAP THERAPY PACK 2153405420B220 2153405420B2 N 4 ESP NM PA_NSOLENVIMA CAP THERAPY PACK 2153405420B230 2153405420B2 N 4 ESP NM PA_NSOLENVIMA CAP THERAPY PACK 2153405420B240 2153405420B2 N 4 ESP NM PA_NSOLENVIMA CAP THERAPY PACK 2153405420B244 2153405420B2 N 4 ESP NM PA_NSOLENVIMA CAP THERAPY PACK 2153405420B250 2153405420B2 N 4 ESP NM PA_NSOLESCOL CAP 39400030100120 394000301001 O 3LESCOL CAP 39400030100140 394000301001 O 3LESCOL XL TAB 39400030107530 394000301075 O 3LETAIRIS TAB 40160007000310 401600070003 N 2 NM PA QL



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITLETAIRIS TAB 40160007000320 401600070003 N 2 NM PA QLletrozole tab 21402860000320 214028600003 Y 1leucovorin calcium inj 21755040102130 217550401021 Y M PA_BvDleucovorin calcium inj 21755040102160 217550401021 Y M PA_BvDleucovorin tab 21755040100310 217550401003 Y 1leucovorin tab 21755040100345 217550401003 Y 1LEUCOVORIN TAB 10MG, 15MG 21755040100325 217550401003 N 1LEUCOVORIN TAB 10MG, 15MG 21755040100335 217550401003 N 1LEUKERAN TAB 21101010000305 211010100003 N 2LEUKINE INJ 82402050002120 824020500021 N 2 NM PA_BvDleuprolide inj 21405010106407 214050101064 Y M PA_BvDlevalbuterol neb 44201045102510 442010451025 Y 2 PA_BvDlevalbuterol neb 44201045102520 442010451025 Y 2 PA_BvDlevalbuterol neb 44201045102530 442010451025 Y 2 PA_BvDlevalbuterol neb 44201045102560 442010451025 Y 2 PA_BvDLEVALBUTEROL/XOPENEX HFA INHALER 44201045503220 442010455032 M 3 QL STLEVAQUIN SOLN 05000034002050 050000340020 O 3LEVAQUIN TAB 05000034000320 050000340003 O 3LEVAQUIN TAB 05000034000330 050000340003 O 3LEVAQUIN TAB 05000034000340 050000340003 O 3LEVAQUIN/D5W INJ 05000034112028 050000341120 O M PA_BvDLEVAQUIN/D5W INJ 05000034112032 050000341120 O M PA_BvDLEVATOL TAB 331000251003 N 3*LEVBID TAB 491010301074 O 3*LEVEMIR FLEXTOUCH 2710400600D220 2710400600D2 N 1LEVEMIR INJ 27104006002020 271040060020 N 1levetiracetam ER tab 72600043007520 726000430075 Y 2levetiracetam ER tab 72600043007530 726000430075 Y 2LEVETIRACETAM IN SODIUM CHLORIDE IV SOLN 72600043052020 726000430520 N M PA_BvDLEVETIRACETAM IN SODIUM CHLORIDE IV SOLN 72600043052030 726000430520 N M PA_BvDLEVETIRACETAM IN SODIUM CHLORIDE IV SOLN 72600043052040 726000430520 N M PA_BvDlevetiracetam inj 72600043002060 726000430020 Y M PA_BvDlevetiracetam soln 72600043002020 726000430020 Y 1levetiracetam tab 72600043000320 726000430003 Y 1levetiracetam tab 72600043000330 726000430003 Y 1levetiracetam tab 72600043000340 726000430003 Y 1levetiracetam tab 72600043000350 726000430003 Y 1levobunolol ophth soln 86250020102005 862500201020 Y 1levobunolol ophth soln 0.25% 862500201020 Y 1*levocarnitine inj 30903045102060 309030451020 Y M PA_BvDlevocarnitine oral soln 30903045102010 309030451020 Y 1 PA_BvD



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITlevocarnitine tab 30903045100330 309030451003 Y 1 PA_BvDlevocetirizine soln 41550027102020 415500271020 Y Mlevocetirizine tab 41550027100320 415500271003 Y Mlevofloxacin inj 05000034002020 050000340020 Y M PA_BvDlevofloxacin opth soln 86101036002020 861010360020 Y 2levofloxacin oral soln 05000034002050 050000340020 Y 1levofloxacin tab 05000034000320 050000340003 Y 1levofloxacin tab 05000034000330 050000340003 Y 1levofloxacin tab 05000034000340 050000340003 Y 1levofloxacin/d5w inj 05000034112024 050000341120 Y M PA_BvDlevofloxacin/d5w inj 05000034112028 050000341120 Y M PA_BvDlevofloxacin/d5w inj 05000034112032 050000341120 Y M PA_BvDlevoleucovorin inj 21755050102120 217550501021 Y M PA_BvDlevoleucovorin inj 50mg 21755050102020 217550501020 Y M NM PA_BvDlevonorgestrel tab 25400040000320 254000400003 Y $0*levonorgestrel tab 25400040000340 254000400003 Y $0*levonorgestrel/ethinyl estradiol tab 68462063729 25994002350320 259940023503 Y 2levora-28 tab 25990002400310 259900024003 Y $0levorphanol tab 65100040100305 651000401003 N 2 QLlevothyroxine tab 28100010100305 281000101003 Y 1levothyroxine tab 28100010100310 281000101003 Y 1levothyroxine tab 28100010100315 281000101003 Y 1levothyroxine tab 28100010100317 281000101003 Y 1levothyroxine tab 28100010100320 281000101003 Y 1levothyroxine tab 28100010100322 281000101003 Y 1levothyroxine tab 28100010100325 281000101003 Y 1levothyroxine tab 28100010100327 281000101003 Y 1levothyroxine tab 28100010100330 281000101003 Y 1levothyroxine tab 28100010100335 281000101003 Y 1levothyroxine tab 28100010100340 281000101003 Y 1levothyroxine tab 28100010100345 281000101003 Y 1LEVSIN INJ 491010301020 N 3*LEVSIN SL TAB 491010301007 O 3*LEVSIN TAB 491010301003 O 3*LEXAPRO SOLN 58160034102020 581600341020 O 3LEXAPRO TAB 58160034100310 581600341003 O 3LEXAPRO TAB 58160034100320 581600341003 O 3LEXAPRO TAB 58160034100330 581600341003 O 3LEXIVA SUSP 12104525101820 121045251018 N 2LEXIVA TAB 12104525100330 121045251003 N 4 ESP NMLIALDA TAB 52500030000670 525000300006 N 2



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITLIBRAX CAP 491099024501 O 3*lidocaine cream 908500601037 Y 1*lidocaine gel 90850060104005 908500601040 Y 1lidocaine inj 69100040102005 691000401020 Y M PA_BvDlidocaine inj 69100040102006 691000401020 Y M PA_BvDlidocaine inj 69100040102010 691000401020 Y M PA_BvDlidocaine inj 69100040102011 691000401020 Y M PA_BvDlidocaine inj 69100040102020 691000401020 Y M PA_BvDlidocaine ointment 90850060004210 908500600042 Y 1LIDOCAINE ORAL SOLN 4% 88350065102045 883500651020 N 1lidocaine patch 90850060005930 908500600059 Y 2 PA QLlidocaine soln 90850060102015 908500601020 Y 1lidocaine viscous soln 88350065102050 883500651020 Y 1lidocaine/hydrocortisone cream 899910022637 Y 1*lidocaine/prilocaine cream 90859902903710 908599029037 Y 1LIDODERM PATCH 90850060005930 908500600059 O 3 PA QLLINCOCIN INJ 300MG/ML 16220010102005 162200101020 O M PA_BvDlincomycin inj 300mg/ml 16220010102005 162200101020 Y M PA_BvDLINDANE LOTION 90900020004110 909000200041 N 2lindane lotion 90900020004110 909000200041 Y 2lindane shampoo 90900020004510 909000200045 Y 2linezolid IV soln 16230040002040 162300400020 Y M NM PAlinezolid susp 100mg/5ml 16230040001920 162300400019 Y 2 NM PAlinezolid tab 16230040000330 162300400003 Y 2 NM PALINZESS CAP 52557050000120 525570500001 N 3 PA QLLINZESS CAP 52557050000140 525570500001 N 3 PA QLliothyronine inj 28100020102020 281000201020 Y M PA_BvDliothyronine tab 28100020100305 281000201003 Y 1liothyronine tab 28100020100310 281000201003 Y 1liothyronine tab 28100020100315 281000201003 Y 1LIPITOR TAB 39400010100310 394000101003 O 3LIPITOR TAB 39400010100320 394000101003 O 3LIPITOR TAB 39400010100330 394000101003 O 3LIPITOR TAB 39400010100350 394000101003 O 3lipodox inj 21200040402210 212000404022 Y M NM PA_BvDLIPOFEN CAP 39200025000110 392000250001 M MLIPOFEN CAP 39200025000124 392000250001 M MLIPOSYN III 80200010001610 802000100016 N M PA_BvDLIPOSYN III 80200010001620 802000100016 O M PA_BvDlisinopril tab 36100030000303 361000300003 Y 1lisinopril tab 36100030000305 361000300003 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITlisinopril tab 36100030000310 361000300003 Y 1lisinopril tab 36100030000315 361000300003 Y 1lisinopril tab 36100030000324 361000300003 Y 1lisinopril tab 36100030000330 361000300003 Y 1lisinopril/hydrochlorothiazide tab 36991802550305 369918025503 Y 1lisinopril/hydrochlorothiazide tab 36991802550310 369918025503 Y 1lisinopril/hydrochlorothiazide tab 36991802550320 369918025503 Y 1lithium carbonate cap 59500010100103 595000101001 Y 1lithium carbonate cap 59500010100105 595000101001 Y 1lithium carbonate cap 59500010100110 595000101001 Y 1lithium carbonate ER tab 59500010100405 595000101004 Y 1lithium carbonate ER tab 59500010100410 595000101004 Y 1lithium carbonate tab 59500010100305 595000101003 Y 1lithium citrate soln 59500010002010 595000100020 Y 1LITHOBID CR TAB 59500010100405 595000101004 O 3LITHOSTAT TAB 56600020000310 566000200003 N 3LIVALO TAB 39400058100320 394000581003 N 3LIVALO TAB 39400058100330 394000581003 N 3LIVALO TAB 39400058100340 394000581003 N 3LO LOESTRIN FE TAB 25991003500320 259910035003 N 3LOCOID CREAM 90550075303705 905500753037 O 3LOCOID LIPOCREAM 90550075323705 905500753237 O 3LOCOID LOTION 90550075304120 905500753041 N MLOCOID OINTMENT 90550075304205 905500753042 O 3LOCOID SOLN 90550075302020 905500753020 O 3LODOSYN TAB 73403030000320 734030300003 O 3LOESTRIN FE TAB 25990003610310 259900036103 O 3LOESTRIN FE TAB 25990003610320 259900036103 O 3LOESTRIN TAB 25990002600310 259900026003 O 3LOESTRIN TAB 25990002600320 259900026003 O 3LOFIBRA CAP 39200025100107 392000251001 N 3LOFIBRA CAP 39200025100115 392000251001 N 3LOFIBRA CAP 39200025100130 392000251001 N 3LOFIBRA TAB 39200025000312 392000250003 N 3LOFIBRA TAB 57844069298 39200025000325 392000250003 N 3LOMOTIL TAB 47100010100310 471000101003 O 3LOMUSTINE CAP 21102020000110 211020200001 N 2LOMUSTINE CAP 21102020000115 211020200001 N 2LOMUSTINE CAP 21102020000120 211020200001 N 2LONSURF TAB 21990002750320 219900027503 N M NM PA_NSOLONSURF TAB 21990002750330 219900027503 N M NM PA_NSO



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITloperamide cap 47100020100105 471000201001 Y MLOPID TAB 39200030000310 392000300003 O 3LOPRESSOR HCT TAB 36992002200310 369920022003 O 3LOPRESSOR HCT TAB 36992002200320 369920022003 O 3LOPRESSOR INJ 33200030102005 332000301020 O M PA_BvDLOPRESSOR TAB 33200030100310 332000301003 O 3LOPRESSOR TAB 33200030100315 332000301003 O 3LOPROX SHAMPOO 90150030004510 901500300045 O 3loratadine ODT 415500300072 Y 1* OTCloratadine syrup 415500300012 Y 1* OTCloratadine tab 415500300003 Y 1* OTCloratadine/pseudoephedrine tab 439930025974 Y 1* OTCloratadine/pseudoephedrine tab 439930025975 Y 1* OTClorazepam intensol conc 57100060001320 571000600013 Y 1lorazepam tab 57100060000305 571000600003 Y 1lorazepam tab 57100060000310 571000600003 Y 1lorazepam tab 57100060000315 571000600003 Y 1losartan tab 36150040200320 361500402003 Y 1losartan tab 36150040200330 361500402003 Y 1losartan tab 36150040200340 361500402003 Y 1losartan/hydrochlorothiazide tab 36994002450320 369940024503 Y 1losartan/hydrochlorothiazide tab 36994002450325 369940024503 Y 1losartan/hydrochlorothiazide tab 36994002450340 369940024503 Y 1LOSEASONIQUE TAB 25993002300315 259930023003 O 3LOTEMAX OPHTH GEL 86300035104020 863000351040 N 2LOTEMAX OPHTH OINTMENT 86300035104230 863000351042 N 2LOTEMAX OPHTH SUSP 86300035101830 863000351018 N 2LOTENSIN TAB 36100005100320 361000051003 O 3LOTENSIN TAB 36100005100330 361000051003 O 3LOTENSIN TAB 36100005100340 361000051003 O 3LOTREL CAP 36991502200120 369915022001 O 3LOTREL CAP 36991502200130 369915022001 O 3LOTREL CAP 36991502200140 369915022001 O 3LOTREL CAP 36991502200145 369915022001 O 3LOTREL CAP 36991502200150 369915022001 O 3LOTREL CAP 36991502200160 369915022001 O 3LOTRISONE CREAM 90159902053710 901599020537 O 3LOTRONEX TAB 52554015100310 525540151003 O 3LOTRONEX TAB 52554015100320 525540151003 O 3lovastatin tab 39400050000305 394000500003 Y 1lovastatin tab 39400050000310 394000500003 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITlovastatin tab 39400050000320 394000500003 Y 1LOVAZA CAP 39500045200130 395000452001 O 3LOVENOX INJ 83101020102012 831010201020 O 3 QLLOVENOX INJ 83101020102013 831010201020 O 3 QLLOVENOX INJ 83101020102014 831010201020 O 3 QLLOVENOX INJ 83101020102015 831010201020 O 3 QLLOVENOX INJ 83101020102016 831010201020 O 3 QLLOVENOX INJ 83101020102018 831010201020 O 3 QLLOVENOX INJ 83101020102020 831010201020 O 3 QLLOVENOX INJ 83101020102050 831010201020 O 3 QLloxapine cap 59154020200105 591540202001 Y 1loxapine cap 59154020200110 591540202001 Y 1loxapine cap 59154020200115 591540202001 Y 1loxapine cap 59154020200120 591540202001 Y 1LTA 360 KIT 88350065102045 883500651020 O 3LUFYLLIN TAB 44300020000315 443000200003 N 3LUMIGAN OPHT SOLN 0.01% 86330015002010 863300150020 N 2 QLLUNESTA TAB 60204035000320 602040350003 O 3 QLLUNESTA TAB 60204035000330 602040350003 O 3 QLLUNESTA TAB 60204035000340 602040350003 O 3 QLLUPRON DEPO-PED INJ 30080050106430 300800501064 N M NM PA_BvDLUPRON DEPO-PED INJ 30080050106440 300800501064 N M NM PA_BvDLUPRON DEPOT INJ 21405010106405 214050101064 N M NM PA_BvDLUPRON DEPOT INJ 21405010106410 214050101064 N M NM PA_BvDLUPRON DEPOT INJ 21405010156420 214050101564 N M NM PA_BvDLUPRON DEPOT INJ 21405010156430 214050101564 N M NM PA_BvDLUPRON DEPOT INJ 21405010206430 214050102064 N M NM PA_BvDLUPRON DEPOT INJ 21405010256450 214050102564 N M NM PA_BvDLUPRON DEPOT INJ 30080050156440 300800501564 N M NM PA_BvDLURIDE SOLN 793000200020 O $0*LURIDE TAB 793000200005 O $0*LUXIQ FOAM 90550020103920 905500201039 O 3LYNPARZA CAP 21535560000120 215355600001 N M NM PA_NSOLYRICA CAP 72600057000110 726000570001 N 2 PA_NSOLYRICA CAP 72600057000115 726000570001 N 2 PA_NSOLYRICA CAP 72600057000120 726000570001 N 2 PA_NSOLYRICA CAP 72600057000125 726000570001 N 2 PA_NSOLYRICA CAP 72600057000135 726000570001 N 2 PA_NSOLYRICA CAP 72600057000145 726000570001 N 2 PA_NSOLYRICA CAP 72600057000150 726000570001 N 2 PA_NSOLYRICA CAP 72600057000160 726000570001 N 2 PA_NSO



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITLYRICA SOLN 72600057002020 726000570020 N 2 PA_NSOLYSODREN TAB 21402250000320 214022500003 N 2LYSTEDA TAB 84100040000320 841000400003 O 3MACROBID CAP 53000050150120 530000501501 O 3MACRODANTIN CAP 25MG 53000050100110 530000501001 O 2MACRODANTIN CAP 50MG, 100MG 53000050100115 530000501001 O 3MACRODANTIN CAP 50MG, 100MG 53000050100120 530000501001 O 3magnesium sulfate inj 79400010402020 794000104020 Y M PA_BvDMAGNESIUM SULFATE INJ 79400010402040 794000104020 O M PA_BvDmagnesium sulfate inj 79400010402040 794000104020 Y M PA_BvDMAGNESIUM SULFATE INJ 79400010402045 794000104020 O M PA_BvDmagnesium sulfate inj 79400010402045 794000104020 Y M PA_BvDMAGNESIUM SULFATE INJ 79400010402050 794000104020 O M PA_BvDmagnesium sulfate inj 79400010402050 794000104020 Y M PA_BvDMAGNESIUM SULFATE INJ 79400010402055 794000104020 O M PA_BvDmagnesium sulfate inj 79400010402055 794000104020 Y M PA_BvDMAGNESIUM SULFATE INJ 79400010402065 794000104020 O M PA_BvDmagnesium sulfate inj 79400010402065 794000104020 Y M PA_BvDMAGNESIUM SULFATE/D5W INJ 79400010412020 794000104120 O M PA_BvDmagnesium sulfate/d5w inj 79400010412020 794000104120 Y M PA_BvDMALARONE TAB 13990002050310 139900020503 M 2MALARONE TAB 13990002050310 139900020503 O 2MALARONE TAB 13990002050320 139900020503 O 2malathion lotion 90900030004120 909000300041 Y 2MANDELAMINE TAB 530000201003 N 3*MAPROTILINE TAB 58300010100305 583000101003 N 1MAPROTILINE TAB 58300010100310 583000101003 N 1MAPROTILINE TAB 58300010100315 583000101003 N 1MARINOL CAP 50300030000110 503000300001 O 3 PAMARINOL CAP 50300030000115 503000300001 O 3 PAMARINOL CAP 50300030000120 503000300001 O 3 PAMARPLAN TAB 58100010000305 581000100003 N 2MARQIBO INJ 21500020201820 215000202018 N M NM PA_BvDMATULANE CAP 21700050100105 217000501001 N 2MAVIK TAB 36100060000310 361000600003 O 3MAVIK TAB 36100060000320 361000600003 O 3MAVIK TAB 36100060000340 361000600003 O 3MAXALT MLT TAB 67406060107220 674060601072 O 3 QLMAXALT MLT TAB 67406060107230 674060601072 O 3 QLMAXALT TAB 67406060100310 674060601003 O 3 QLMAXALT TAB 67406060100320 674060601003 O 3 QL



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITMAXIDEX OPHTH SUSP 86300010001805 863000100018 N 2MAXIPIME INJ 02400040102110 024000401021 O M PA_BvDMAXIPIME INJ 02400040102120 024000401021 O M PA_BvDMAXITROL OPHTH OINTMENT 86309903324210 863099033242 O 3MAXITROL OPHTH SUSP 86309903321810 863099033218 O 3MAXZIDE TAB 37990002300315 379900023003 O 3MAXZIDE TAB 37990002300330 379900023003 O 3meclizine chew tab 502000500005 Y 1*meclizine tab 50200050000305 502000500003 Y 1meclizine tab 50200050000310 502000500003 Y 1MECLOFENAMATE CAP 66100040100105 661000401001 N 1MECLOFENAMATE CAP 66100040100110 661000401001 N 1MEDROL TAB 2MG 22100030000305 221000300003 N 1MEDROL TAB 4MG, 8MG, 16MG, 32MG 22100030000310 221000300003 O 3MEDROL TAB 4MG, 8MG, 16MG, 32MG 22100030000315 221000300003 O 3MEDROL TAB 4MG, 8MG, 16MG, 32MG 22100030000320 221000300003 O 3MEDROL TAB 4MG, 8MG, 16MG, 32MG 22100030000330 221000300003 O 3MEDROL TAB DOSE PACK 2210003000B705 2210003000B7 O 3medroxyprogesterone acetate tab 26000020200305 260000202003 Y 1medroxyprogesterone acetate tab 26000020200310 260000202003 Y 1medroxyprogesterone acetate tab 26000020200315 260000202003 Y 1medroxyprogesterone inj 25150035101820 251500351018 Y $0medroxyprogesterone inj 2515003510E620 2515003510E6 Y $0mefenamic acid 66100050000105 661000500001 Y 2mefloquine tab 13000025100310 130000251003 Y 2MEGACE ES SUSP 26000023201840 260000232018 O 3MEGACE ORAL SUSP 21404020101810 214040201018 O 3megestrol acetate susp 21404020101810 214040201018 Y 1megestrol acetate tab 21404020100305 214040201003 Y 1megestrol acetate tab 21404020100310 214040201003 Y 1megestrol ES susp 26000023201840 260000232018 Y 2MEKINIST TAB 21533570100310 215335701003 N 2 NM PA_NSOMEKINIST TAB 21533570100330 215335701003 N 2 NM PA_NSOmeloxicam tab 66100052000320 661000520003 Y 1meloxicam tab 66100052000330 661000520003 Y 1melphalan inj 21101040102110 211010401021 Y M NM PA_BvDmemantine soln 62053550102020 620535501020 Y 2memantine tab 62053550100320 620535501003 Y 1memantine tab 62053550100330 620535501003 Y 1memantine tab titration pack 62053550100350 620535501003 Y 1MENACTRA INJ 17200040442200 172000404422 N $0



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITMENEST TAB 24000030000305 240000300003 N 3MENEST TAB 24000030000310 240000300003 N 3MENEST TAB 24000030000315 240000300003 N 3MENEST TAB 24000030000320 240000300003 N 3MENHIBRIX INJ 17209902502120 172099025021 N $0MENOMUNE A/C/Y/W INJ 17200040402200 172000404022 N $0MENOSTAR PATCH 24000035008805 240000350088 N 3MENTAX CREAM 90150026103720 901500261037 N 3MENVEO INJ 17200040482100 172000404821 N $0meperidine inj 65100045102010 651000451020 Y Mmeperidine inj 65100045102015 651000451020 Y Mmeperidine inj 65100045102030 651000451020 Y MMEPERIDINE ORAL SOLN 65100045102060 651000451020 N Mmeperidine tab 100mg 65100045100310 651000451003 Y 1 QLmeperidine tab 50mg 65100045100305 651000451003 Y 1 QLMEPHYTON TAB 772040300003 N 2*meprobamate tab 57200050000305 572000500003 Y 1meprobamate tab 57200050000310 572000500003 Y 1MEPRON SUSP 16400020001820 164000200018 O 3mercaptopurine tab 21300040000305 213000400003 Y 2meropenem inj 16150050002120 161500500021 Y M PA_BvDmeropenem inj 16150050002140 161500500021 Y M PA_BvDMERREM INJ 16150050002120 161500500021 O M PA_BvDMERREM INJ 16150050002140 161500500021 O M PA_BvDmesalamine enema 52500030005105 525000300051 Y 2mesalamine enema kit 52500030206420 525000302064 Y Mmesna inj 21758050002010 217580500020 Y M PA_BvDMESNEX INJ 21758050002010 217580500020 O M PA_BvDMESNEX TAB 21758050000320 217580500003 N 2MESTINON SYRUP 76000050101205 760000501012 N 3MESTINON TAB 76000050100305 760000501003 O 3MESTINON TIMESPAN TAB 180MG 76000050100405 760000501004 O 3METADATE CD CAP 61400020100210 614000201002 O 3METADATE CD CAP 61400020100220 614000201002 O 3METADATE CD CAP 61400020100230 614000201002 O 3METADATE CD CAP 61400020100240 614000201002 O 3METADATE CD CAP 61400020100250 614000201002 O 3METADATE CD CAP 61400020100260 614000201002 O 3METAPROTERENOL SYRUP 44201050201205 442010502012 N 1METAPROTERENOL TAB 44201050200305 442010502003 N 3METAPROTERENOL TAB 44201050200310 442010502003 N 3



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITmetaxalone tab 75100060000320 751000600003 Y 2METAXALONE TAB 400MG 75100060000310 751000600003 N Mmetformin ER osmotic tab 27250050007560 272500500075 Y NCmetformin ER osmotic tab 27250050007570 272500500075 Y NCmetformin ER tab 500mg, 750mg 27250050007520 272500500075 Y 1metformin ER tab 500mg, 750mg 27250050007530 272500500075 Y 1metformin tab 27250050000320 272500500003 Y 1metformin tab 27250050000340 272500500003 Y 1metformin tab 27250050000350 272500500003 Y 1methadone conc 65100050101310 651000501013 Y 1METHADONE INJ 65100050102005 651000501020 N M PA_BvDMETHADONE INTENSOL CONC 65100050101310 651000501013 O 3METHADONE ORAL SOLN 10MG/5ML 65100050102015 651000501020 N 1 QLmethadone oral soln 10mg/5ml 65100050102015 651000501020 Y 1 QLMETHADONE ORAL SOLN 5MG/5ML 65100050102010 651000501020 N 1 QLmethadone oral soln 5mg/5ml 65100050102010 651000501020 Y 1 QLmethadone tab 65100050100305 651000501003 Y 1 QLmethadone tab 65100050100310 651000501003 Y 1 QLMETHADOSE TAB 651000501073 N 2*methadose tab 651000501073 Y 1*methamphetamine tab 61100030100305 611000301003 Y 1methazolamide tab 37100030000303 371000300003 Y 1methazolamide tab 37100030000305 371000300003 Y 1methenamine hippurate tab 53000020200305 530000202003 Y 2METHERGINE TAB 29000020100305 290000201003 O 2 QLmethimazole tab 28300010000305 283000100003 Y 1methimazole tab 28300010000310 283000100003 Y 1METHITEST TAB 23100020000310 231000200003 N 3 PAmethocarbamol tab 75100070000305 751000700003 Y 1methocarbamol tab 75100070000310 751000700003 Y 1methotrexate inj 21300050102150 213000501021 Y 1METHOTREXATE INJ 250MG/10ML 21300050102068 213000501020 N 1methotrexate inj 50mg/2ml 21300050102062 213000501020 Y 1methotrexate PF inj 25mg/ml 21300050102063 213000501020 Y 1methotrexate PF inj 25mg/ml 21300050102065 213000501020 Y 1methotrexate PF inj 25mg/ml 21300050102067 213000501020 Y 1methotrexate PF inj 25mg/ml 21300050102069 213000501020 Y 1methotrexate PF inj 25mg/ml 21300050102075 213000501020 Y 1methotrexate tab 21300050100310 213000501003 Y 1methoxsalen cap 90250560100110 902505601001 Y 2methscopolamine tab 49102060100305 491020601003 Y 2



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITmethscopolamine tab 49102060100320 491020601003 Y 2METHYCLOTHIAZIDE TAB 37600055000310 376000550003 N 1methyldopa tab 36201030000310 362010300003 Y 1methyldopa tab 36201030000315 362010300003 Y 1methyldopa/hydrochlorothiazide tab 36995002700310 369950027003 Y 1methyldopa/hydrochlorothiazide tab 36995002700320 369950027003 Y 1methylergonovine tab 29000020100305 290000201003 Y 2 QLMETHYLIN CHEW TAB 61400020100510 614000201005 O 3METHYLIN CHEW TAB 61400020100520 614000201005 O 3METHYLIN CHEW TAB 61400020100530 614000201005 O 3METHYLIN SOLN 61400020102020 614000201020 O 2METHYLIN SOLN 61400020102030 614000201020 O 2methylphenidate CD cap 61400020100210 614000201002 Y 2methylphenidate CD cap 61400020100220 614000201002 Y 2methylphenidate CD cap 61400020100230 614000201002 Y 2methylphenidate CD cap 61400020100240 614000201002 Y 2methylphenidate CD cap 61400020100250 614000201002 Y 2methylphenidate CD cap 61400020100260 614000201002 Y 2methylphenidate chew tab 61400020100510 614000201005 Y 2methylphenidate chew tab 61400020100520 614000201005 Y 2methylphenidate chew tab 61400020100530 614000201005 Y 2methylphenidate ER cap 61400020107020 614000201070 Y 2methylphenidate ER cap 61400020107030 614000201070 Y 2methylphenidate ER cap 61400020107040 614000201070 Y 2METHYLPHENIDATE ER TAB 61400020107518 614000201075 M 2methylphenidate ER tab 10mg, 20mg 61400020100403 614000201004 Y 1methylphenidate ER tab 10mg, 20mg 61400020100405 614000201004 Y 1METHYLPHENIDATE ER TAB 18MG, 27MG, 36MG, 54MG 61400020107518 614000201075 N 2METHYLPHENIDATE ER TAB 18MG, 27MG, 36MG, 54MG 61400020107527 614000201075 N 2METHYLPHENIDATE ER TAB 18MG, 27MG, 36MG, 54MG 61400020107536 614000201075 N 2METHYLPHENIDATE ER TAB 18MG, 27MG, 36MG, 54MG 61400020107554 614000201075 N 2METHYLPHENIDATE ER TAB 18MG, 27MG, 36MG, 54MG 00591271501 61400020100460 614000201004 M 2METHYLPHENIDATE ER TAB 18MG, 27MG, 36MG, 54MG 00591271601 61400020100465 614000201004 M 2METHYLPHENIDATE ER TAB 18MG, 27MG, 36MG, 54MG 00591271701 61400020100470 614000201004 M 2METHYLPHENIDATE ER TAB 18MG, 27MG, 36MG, 54MG 00591271730 61400020100470 614000201004 M 2METHYLPHENIDATE ER TAB 18MG, 27MG, 36MG, 54MG 00591271801 61400020100480 614000201004 M 2METHYLPHENIDATE ER TAB 18MG, 27MG, 36MG, 54MG 00591271830 61400020100480 614000201004 M 2methylphenidate soln 61400020102020 614000201020 Y 2methylphenidate soln 61400020102030 614000201020 Y 2methylphenidate tab 61400020100305 614000201003 Y 1methylphenidate tab 61400020100310 614000201003 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITmethylphenidate tab 61400020100315 614000201003 Y 1methylprednisolone acetate inj 22100030101810 221000301018 Y M PA_BvDmethylprednisolone acetate inj 22100030101815 221000301018 Y M PA_BvDmethylprednisolone inj 22100030202105 221000302021 Y M PA_BvDmethylprednisolone inj 22100030202110 221000302021 Y M PA_BvDmethylprednisolone pak 2210003000B705 2210003000B7 Y 1METHYLPREDNISOLONE PF INJ 22100030101811 221000301018 N M PA_BvDMETHYLPREDNISOLONE PF INJ 22100030101816 221000301018 N M PA_BvDMETHYLPREDNISOLONE PF INJ 22100030101825 221000301018 N M PA_BvDmethylprednisolone succinate inj 22100030202120 221000302021 Y M PA_BvDmethylprednisolone tab 22100030000310 221000300003 Y 1methylprednisolone tab 22100030000315 221000300003 Y 1methylprednisolone tab 22100030000320 221000300003 Y 1methylprednisolone tab 22100030000330 221000300003 Y 1methyltestosterone cap 10mg 23100020000105 231000200001 Y 2 PAMETIPRANOLOL OPHTH SOLN 86250015102020 862500151020 N 2metoclopramide inj 52300020102005 523000201020 Y M PA_BvDmetoclopramide soln 52300020102013 523000201020 Y 1metoclopramide tab 52300020100303 523000201003 Y 1metoclopramide tab 52300020100305 523000201003 Y 1metolazone tab 37600060000305 376000600003 Y 1metolazone tab 37600060000310 376000600003 Y 1metolazone tab 37600060000315 376000600003 Y 1metoprolol ER tab 33200030057510 332000300575 Y 1metoprolol ER tab 33200030057520 332000300575 Y 1metoprolol ER tab 33200030057530 332000300575 Y 1metoprolol ER tab 33200030057540 332000300575 Y 1metoprolol inj 33200030102005 332000301020 Y M PA_BvDmetoprolol tab 33200030100305 332000301003 Y 1metoprolol tab 33200030100310 332000301003 Y 1metoprolol tab 33200030100315 332000301003 Y 1metoprolol/hydrochlorothiazide tab 36992002200310 369920022003 Y 2metoprolol/hydrochlorothiazide tab 36992002200320 369920022003 Y 2metoprolol/hydrochlorothiazide tab 36992002200325 369920022003 Y 2METROCREAM 90060040003710 900600400037 O 3METROGEL 90060040004020 900600400040 O 3 STMETROGEL VAGINAL GEL 55100035004020 551000350040 O 3METROLOTION 90060040004110 900600400041 O 3metronidazole cap 16000035000107 160000350001 Y 1metronidazole cream 90060040003710 900600400037 Y 2metronidazole gel 90060040004010 900600400040 Y 2



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITmetronidazole gel 90060040004020 900600400040 Y 2metronidazole lotion 90060040004110 900600400041 Y 1metronidazole tab 16000035000305 160000350003 Y 1metronidazole tab 16000035000310 160000350003 Y 1metronidazole vaginal gel 55100035004020 551000350040 Y 1metronidazole/nacl inj 16000035112020 160000351120 Y M PA_BvDMEVACOR TAB 39400050000320 394000500003 O 3mexiletine cap 35200025100105 352000251001 Y 2mexiletine cap 35200025100110 352000251001 Y 2mexiletine cap 35200025100115 352000251001 Y 2MIACALCIN INJ 30043020002020 300430200020 N 4 PA_BvDMIACALCIN NASAL SPRAY 30043020002080 300430200020 O 3MICARDIS HCT TAB 36994002600320 369940026003 O 3MICARDIS HCT TAB 36994002600340 369940026003 O 3MICARDIS HCT TAB 36994002600345 369940026003 O 3MICARDIS TAB 36150070000310 361500700003 O 3MICARDIS TAB 36150070000320 361500700003 O 3MICARDIS TAB 36150070000340 361500700003 O 3MICONAZOLE 3 SUPP 55104050105210 551040501052 N 3MICRO-K CAP 797000300002 O 3*MICROZIDE CAP 37600040000110 376000400001 O 3midodrine tab 38000083100320 380000831003 Y 1midodrine tab 38000083100330 380000831003 Y 1midodrine tab 38000083100340 380000831003 Y 1miglitol tab 27500050000310 275000500003 Y 2miglitol tab 27500050000320 275000500003 Y 2miglitol tab 27500050000340 275000500003 Y 2MIGRANAL/DIHYDROERGOTAMINE SPRAY 67000030102060 670000301020 M 3 QLMILLIPRED DP PAK 2210004000B720 2210004000B7 N 3MILLIPRED DP PAK 2210004000B730 2210004000B7 N 3MILLIPRED SOLN 22100040202050 221000402020 N 3MILLIPRED TAB 22100040000305 221000400003 N 3mimvey LO tab 24993002120305 249930021203 Y 2mimvey tab 24993002120310 249930021203 Y 2MINASTRIN CHEW TAB 25990003610512 259900036105 N 3MINIPRESS CAP 36202030100105 362020301001 O 3MINIPRESS CAP 36202030100110 362020301001 O 3MINIPRESS CAP 36202030100115 362020301001 O 3minitran patch 32100030008510 321000300085 Y 1minitran patch 32100030008520 321000300085 Y 1minitran patch 32100030008540 321000300085 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITminitran patch 32100030008550 321000300085 Y 1MINOCIN CAP 04000040100105 040000401001 O 3MINOCIN CAP 04000040100107 040000401001 O 3MINOCIN CAP 04000040100110 040000401001 O 3minocycline cap 04000040100105 040000401001 Y 1minocycline cap 04000040100107 040000401001 Y 1minocycline cap 04000040100110 040000401001 Y 1minocycline tab 04000040100305 040000401003 Y 2minocycline tab 04000040100307 040000401003 Y 2minocycline tab 04000040100310 040000401003 Y 2minoxidil tab 36400020000305 364000200003 Y 1minoxidil tab 36400020000310 364000200003 Y 1MIOSTAT INJ 86501020002005 865010200020 N NCMIRAPEX ER TAB 73203060107520 732030601075 O 3MIRAPEX ER TAB 73203060107530 732030601075 N 3MIRAPEX ER TAB 73203060107530 732030601075 O 3MIRAPEX ER TAB 73203060107540 732030601075 N 3MIRAPEX ER TAB 73203060107540 732030601075 O 3MIRAPEX ER TAB 73203060107545 732030601075 O 3MIRAPEX ER TAB 73203060107555 732030601075 O 3MIRAPEX ER TAB 73203060107550 732030601075 O 3MIRAPEX ER TAB 73203060107560 732030601075 O 3MIRAPEX TAB 73203060100305 732030601003 O 3MIRAPEX TAB 73203060100310 732030601003 O 3MIRAPEX TAB 73203060100315 732030601003 O 3MIRAPEX TAB 73203060100317 732030601003 O 3MIRAPEX TAB 73203060100320 732030601003 O 3MIRAPEX TAB 73203060100330 732030601003 O 3MIRCETTE TAB 25991002050320 259910020503 O 3MIRENA IUD 252000500053 N $0*mirtazapine ODT 58030050007215 580300500072 Y 1mirtazapine ODT 58030050007230 580300500072 Y 1mirtazapine ODT 58030050007245 580300500072 Y 1mirtazapine tab 58030050000308 580300500003 Y 1mirtazapine tab 58030050000315 580300500003 Y 1mirtazapine tab 58030050000330 580300500003 Y 1mirtazapine tab 58030050000345 580300500003 Y 1misoprostol tab 49250030000310 492500300003 Y 1misoprostol tab 49250030000320 492500300003 Y 1MITIGARE CAP 68000020000120 680000200001 M Mmitomycin inj 21200050002110 212000500021 Y M PA_BvD



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITmitomycin inj 21200050002120 212000500021 Y M PA_BvDmitoxantrone inj 21200055001320 212000550013 Y M PA_BvDmitoxantrone inj 21200055001325 212000550013 Y M PA_BvDmitoxantrone inj 21200055001330 212000550013 Y M PA_BvDM-M-R II INJ 17109903102200 171099031022 N $0MOBIC SUSP 66100052001820 661000520018 M 3MOBIC TAB 66100052000320 661000520003 O 3MOBIC TAB 66100052000330 661000520003 O 3modafinil tab 61400024000310 614000240003 Y 2 PA QLmodafinil tab 61400024000320 614000240003 Y 2 PA QLmoexipril tab 36100033100310 361000331003 Y 1moexipril tab 36100033100320 361000331003 Y 1moexipril/hydrochlorothiazide tab 36991802600310 369918026003 Y 1moexipril/hydrochlorothiazide tab 36991802600316 369918026003 Y 1moexipril/hydrochlorothiazide tab 36991802600320 369918026003 Y 1MOLINDONE TAB 59160050100305 591600501003 N MMOLINDONE TAB 59160050100310 591600501003 N MMOLINDONE TAB 59160050100315 591600501003 N Mmometasone cream 90550082103710 905500821037 Y 1mometasone furoate ointment 90550082104210 905500821042 Y 1mometasone lotion 90550082102010 905500821020 Y 1mometasone nasal spray 42200045101820 422000451018 Y NCmontelukast chew tab 44505050100516 445050501005 Y 1montelukast chew tab 44505050100520 445050501005 Y 1montelukast granules 44505050103020 445050501030 Y 2montelukast tab 44505050100330 445050501003 Y 1MONUROL PACKET 53000015203020 530000152030 N 3MORPHINE SULFATE ER BEAD CAP 65100055207020 651000552070 N 2 QLMORPHINE SULFATE ER BEAD CAP 65100055207025 651000552070 N 2 QLMORPHINE SULFATE ER BEAD CAP 65100055207030 651000552070 N 2 QLMORPHINE SULFATE ER BEAD CAP 65100055207035 651000552070 N 2 QLMORPHINE SULFATE ER BEAD CAP 65100055207040 651000552070 N 2 QLMORPHINE SULFATE ER BEAD CAP 65100055207050 651000552070 N 2 QLmorphine sulfate ER cap 65100055107010 651000551070 Y 2 QLmorphine sulfate ER cap 65100055107020 651000551070 Y 2 QLmorphine sulfate ER cap 65100055107030 651000551070 Y 2 QLmorphine sulfate ER cap 65100055107040 651000551070 Y 2 QLmorphine sulfate ER cap 65100055107045 651000551070 Y 2 QLmorphine sulfate ER cap 65100055107050 651000551070 Y 2 QLmorphine sulfate ER cap 65100055107060 651000551070 Y 2 QLmorphine sulfate ER tab 65100055100415 651000551004 Y 1 QL



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITmorphine sulfate ER tab 65100055100432 651000551004 Y 1 QLmorphine sulfate ER tab 65100055100445 651000551004 Y 1 QLmorphine sulfate ER tab 65100055100460 651000551004 Y 1 QLmorphine sulfate ER tab 65100055100480 651000551004 Y 1 QLmorphine sulfate inj 65100055102004 651000551020 Y M PA_BvDMORPHINE SULFATE INJ 65100055102005 651000551020 N M PA_BvDMORPHINE SULFATE INJ 65100055102010 651000551020 N M PA_BvDMORPHINE SULFATE INJ 65100055102015 651000551020 N M PA_BvDMORPHINE SULFATE INJ 65100055102017 651000551020 N M PA_BvDmorphine sulfate inj 65100055102025 651000551020 Y M PA_BvDMORPHINE SULFATE INJ 65100055102030 651000551020 N M PA_BvDmorphine sulfate inj 65100055102030 651000551020 Y M PA_BvDMORPHINE SULFATE INJ 65100055102040 651000551020 N M PA_BvDmorphine sulfate inj 65100055102040 651000551020 Y M PA_BvDMORPHINE SULFATE INJ 65100055102044 651000551020 N M PA_BvDMORPHINE SULFATE INJ 65100055102049 651000551020 N M PA_BvDmorphine sulfate inj 65100055102054 651000551020 Y M PA_BvDMORPHINE SULFATE INJ 65100055102055 651000551020 N M PA_BvDMORPHINE SULFATE INJ 65100055102058 651000551020 O M PA_BvDmorphine sulfate inj 65100055102058 651000551020 Y M PA_BvDMORPHINE SULFATE INJ 65100055102059 651000551020 O M PA_BvDmorphine sulfate inj 65100055102059 651000551020 Y M PA_BvDMORPHINE SULFATE INJ 65100055102060 651000551020 O M PA_BvDmorphine sulfate inj 65100055102060 651000551020 Y M PA_BvDmorphine sulfate soln 10mg/5ml 65100055102065 651000551020 Y 1 QLmorphine sulfate soln 20mg/5ml 65100055102070 651000551020 Y 1 QLmorphine sulfate soln 20mg/ml 65100055102090 651000551020 Y 1 QLmorphine sulfate tab 65100055100310 651000551003 Y 1 QLmorphine sulfate tab 65100055100315 651000551003 Y 1 QLMOTRIN SUSP (OTC) 661000200018 O 3* OTCMOTRIN SUSP (RX) 66100020001820 661000200018 O 3MOVANTIK TAB 52580060300320 525800603003 N M PAMOVANTIK TAB 52580060300330 525800603003 N M PAMOVIPREP 46992006302120 469920063021 N 2MOXEZA OPHTH SOLN 86101038102025 861010381020 N 2MOXIFLOXACIN INJ 05000037102020 050000371020 N M PA_BvDmoxifloxacin tab 05000037100320 050000371003 Y 2MOZOBIL INJ 82502060002020 825020600020 N M NM PA_BvDMS CONTIN TAB 65100055100415 651000551004 O 3 QLMS CONTIN TAB 65100055100432 651000551004 O 3 QLMS CONTIN TAB 65100055100445 651000551004 O 3 QL



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITMS CONTIN TAB 65100055100460 651000551004 O 3 QLMS CONTIN TAB 65100055100480 651000551004 O 3 QLMULTAQ TAB 35400028100320 354000281003 N 2multigen folic tab 829920062003 Y 1*multigen plus tab 829920075003 Y 1*multigen tab 829920061503 Y 1*MULTIVITAMIN TAB 829920043003 O 3*multivitamin tab 829920043003 Y 3*multivitamins w/ minerals tab 783100000003 Y 1* OTCmupirocin cream 90100065203710 901000652037 Y 2mupirocin ointment 90100065104210 901000651042 Y 2MUSTARGEN INJ 21101030102105 211010301021 N M PA_BvDMYAMBUTOL TAB 09000040100310 090000401003 O 3MYCAMINE INJ 11500050102120 115000501021 N M PA_BvDMYCAMINE INJ 11500050102130 115000501021 N M PA_BvDMYCOBUTIN CAP 09000075000120 090000750001 O 3mycophenolate cap 99403030100120 994030301001 Y 1 PA_BvDmycophenolate DR tab 99403030300620 994030303006 Y 2 PA_BvDmycophenolate DR tab 99403030300630 994030303006 Y 2 PA_BvDmycophenolate mofetil susp 99403030101920 994030301019 Y 2 PA_BvDmycophenolate tab 99403030100330 994030301003 Y 1 PA_BvDMYDFRIN OPHTH SOLN 864000401020 O 3*MYDRIACYL OPHTH SOLN 863500500020 O 3*MYFORTIC TAB 99403030300620 994030303006 O 3 PA_BvDMYFORTIC TAB 99403030300630 994030303006 O 3 PA_BvDMYOZYME/LUMIZYME INJ 30907715002120 309077150021 N M NM PA_BvDMYRBETRIQ TAB 54200050007520 542000500075 N 2MYRBETRIQ TAB 54200050007530 542000500075 N 2MYSOLINE TAB 72600060000305 726000600003 O 3MYSOLINE TAB 72600060000310 726000600003 O 3nabumetone tab 66100055000320 661000550003 Y 1nabumetone tab 66100055000330 661000550003 Y 1nadolol tab 33100010000303 331000100003 Y 1nadolol tab 33100010000305 331000100003 Y 1nadolol tab 33100010000310 331000100003 Y 1nadolol/bendroflumethiazide tab 36992002300310 369920023003 Y Mnadolol/bendroflumethiazide tab 36992002300320 369920023003 Y MNAFCILLIN SODIUM IN DEXTROSE INJ 01300040112020 013000401120 N M PA_BvDNAFTIFINE CREAM 1% 90150078003710 901500780037 N 2naftifine cream 2% 90150078003720 901500780037 Y 2NAFTIN CREAM 1% 90150078003710 901500780037 O 3



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITNAFTIN CREAM 2% 90150078003720 901500780037 O 2NAFTIN GEL 90150078004010 901500780040 N 2NAFTIN GEL 90150078004030 901500780040 N 2NAGLAZYME INJ 30907535002020 309075350020 N M NM PA_BvDNALLPEN/DEX INJ 01300040112025 013000401120 N M PA_BvDnaloxone inj 93400020102030 934000201020 Y Mnaloxone inj 0.4mg/ml 93400020102010 934000201020 Y MNALOXONE INJ 2MG/2ML 9340002010E540 9340002010E5 N 2NALOXONE SOLN CARTRIDGE 9340002010E210 9340002010E2 N MNAMENDA SOLN 62053550102020 620535501020 O 3NAMENDA TAB 62053550100320 620535501003 O 3NAMENDA TAB 62053550100330 620535501003 O 3NAMENDA TAB TITRATION PACK 62053550100350 620535501003 O 3NAMENDA XR CAP 62053550107020 620535501070 N 2NAMENDA XR CAP 62053550107030 620535501070 N 2NAMENDA XR CAP 62053550107040 620535501070 N 2NAMENDA XR CAP 62053550107050 620535501070 N 2NAMENDA XR CAP 62053550107080 620535501070 N 2NAMZARIC CAP 62059902507030 620599025070 N 2 STNAMZARIC ER CAP 62059902507020 620599025070 N 2 STNAMZARIC ER CAP 62059902507040 620599025070 N 2 STNAMZARIC ER CAP 62059902507050 620599025070 N 2 STNAMZARIC STARTER PACK 6205990250B630 6205990250B6 N 2 STNAPHAZOLINE OPHTH SOLN 86400030102020 864000301020 N MNAPRELAN CR TAB 375MG, 500MG 66100060107520 661000601075 O MNAPRELAN CR TAB 375MG, 500MG 66100060107540 661000601075 O MNAPROSYN SUSP 66100060001805 661000600018 O 3NAPROSYN TAB 66100060000305 661000600003 O 3NAPROSYN TAB 66100060000310 661000600003 O 3NAPROSYN TAB 66100060000315 661000600003 O 3naproxen CR tab 375mg, 500mg 66100060107520 661000601075 Y Mnaproxen CR tab 375mg, 500mg 66100060107540 661000601075 Y Mnaproxen EC tab 66100060000610 661000600006 Y 1naproxen EC tab 66100060000615 661000600006 Y 1naproxen sodium tab 66100060100305 661000601003 Y 1naproxen sodium tab 66100060100310 661000601003 Y 1NAPROXEN SR TAB 750MG 66100060107550 661000601075 N 3NAPROXEN SUSP 66100060001805 661000600018 N 2naproxen susp 66100060001805 661000600018 Y 2naproxen tab 66100060000305 661000600003 Y 1naproxen tab 66100060000310 661000600003 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITnaproxen tab 66100060000315 661000600003 Y 1naratriptan tab 67406050100310 674060501003 Y 2 QLnaratriptan tab 67406050100320 674060501003 Y 2 QLNARDIL TAB 58100020100305 581000201003 O 2NASACORT ALLERGY 24HR NASAL SPRAY 422000601032 N 1* OTC QLNASACORT OTC NASAL SPRAY 422000601032 O 1* OTC QLNASCOBAL SPRAY 821000100020 N 3*NASONEX NASAL SPRAY 42200045101820 422000451018 O 2 QLNATACYN OPHTH SUSP 86104010001805 861040100018 N MNATAZIA TAB 25992402400320 259924024003 N 3nateglinide tab 27280040000320 272800400003 Y 2nateglinide tab 27280040000330 272800400003 Y 2NATPARA INJ 3004405510E110 3004405510E1 N 4 ESP NM PANATPARA INJ 3004405510E120 3004405510E1 N 4 ESP NM PANATPARA INJ 3004405510E130 3004405510E1 N 4 ESP NM PANATPARA INJ 3004405510E140 3004405510E1 N 4 ESP NM PANAVELBINE INJ 21500050802020 215000508020 O M PA_BvDNAVELBINE INJ 21500050802025 215000508020 O M PA_BvDNEBUPENT NEB 16000045002170 160000450021 N 2 PA_BvDnecon tab 25990002500310 259900025003 Y $0necon tab 25990002700310 259900027003 Y $0necon tab 25991002200310 259910022003 Y $0NEFAZODONE TAB 100MG, 150MG, 200MG 58120050100310 581200501003 N 1NEFAZODONE TAB 100MG, 150MG, 200MG 58120050100320 581200501003 N 1NEFAZODONE TAB 100MG, 150MG, 200MG 58120050100330 581200501003 N 1nefazodone tab 250mg 58120050100340 581200501003 Y 1nefazodone tab 50mg 58120050100305 581200501003 Y 1neomycin tab 07000040100305 070000401003 Y 1neomycin/bacitracin/polymyxin ophth ointment 86109903104220 861099031042 Y 1neomycin/polymyxin gu irrigation soln 56701002102000 567010021020 Y Mneomycin/polymyxin/dexamethasone ophth ointment 86309903324210 863099033242 Y 1neomycin/polymyxin/dexamethasone ophth susp 86309903321810 863099033218 Y 1neomycin/polymyxin/gramicidin ophth soln 86109903202000 861099032020 Y 1neomycin/polymyxin/hydrocortisone ophth susp 86309903341810 863099033418 Y 1neomycin/polymyxin/hydrocortisone otic soln 87991003102010 879910031020 Y 1neomycin/polymyxin/hydrocortisone otic susp 87991003101807 879910031018 Y 1NEORAL CAP 99402020300120 994020203001 O 3 PA_BvDNEORAL CAP 99402020300150 994020203001 O 3 PA_BvDNEORAL SOLN 99402020302020 994020203020 O 3 PA_BvDNEOSPORIN OPHTH SOLN 86109903202000 861099032020 O 3NEOTUSS LIQUID 439980047009 N 3*



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITNEPHRAMINE INJ 80302010102016 803020101020 N M PA_BvDNEPHRO CAP 781330000001 O 3*NEULASTA INJ 8240157000E520 8240157000E5 N 4 ESP NM PA_BvDNEULASTA INJ 8240157000F820 8240157000F8 N 4 ESP NM PA_BvDNEUMEGA INJ 82403060002120 824030600021 N 4 ESP NM PA_BvDNEUPOGEN INJ 82401520002010 824015200020 N 4 ESP NM PA_BvDNEUPOGEN INJ 82401520002012 824015200020 N 4 ESP NM PA_BvDNEUPOGEN INJ 8240152000E545 8240152000E5 N 4 ESP NM PA_BvDNEUPOGEN INJ 8240152000E550 8240152000E5 N 4 ESP NM PA_BvDNEUPRO PATCH 73203075008510 732030750085 N 3NEUPRO PATCH 73203075008520 732030750085 N 3NEUPRO PATCH 73203075008525 732030750085 N 3NEUPRO PATCH 73203075008530 732030750085 N 3NEUPRO PATCH 73203075008540 732030750085 N 3NEUPRO PATCH 73203075008550 732030750085 N 3NEURONTIN CAP 72600030000110 726000300001 O 3NEURONTIN CAP 72600030000130 726000300001 O 3NEURONTIN CAP 72600030000140 726000300001 O 3NEURONTIN SOLN 72600030002020 726000300020 O 3NEURONTIN TAB 72600030000330 726000300003 O 3NEURONTIN TAB 72600030000340 726000300003 O 3NEVANAC OPHTH SUSP 86805050001820 868050500018 N 2nevirapine ER tab 12109050007510 121090500075 Y 2nevirapine ER tab 12109050007520 121090500075 Y 2NEVIRAPINE SUSP 12109050001820 121090500018 M 4nevirapine tab 12109050000320 121090500003 Y 1NEXAVAR TAB 21533060400320 215330604003 N 4 ESP NM PA_NSONEXIUM IV INJ 49270025202140 492700252021 O M PA_BvDNEXTERONE INJ 35400005112020 354000051120 N M PA_BvDNEXTERONE INJ 35400005112030 354000051120 N M PA_BvDniacin cap 771030100002 Y 1*niacin CR tab 771030100004 Y 1* OTCniacin tab (OTC) 771030100003 Y 1* OTCNIACIN TR TAB (OTC) 771030100004 N 1* OTCniacinamide tab 771030200003 Y 1* OTCNIACOR TAB 39450050000350 394500500003 N 1NIASPAN ER TAB 39450050000450 394500500004 O 1NIASPAN ER TAB 39450050000460 394500500004 O 1NIASPAN ER TAB 39450050000470 394500500004 O 1nicardipine cap 34000018100120 340000181001 Y 1nicardipine cap 34000018100125 340000181001 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITnicardipine inj 34000018102020 340000181020 Y M PA_BvDNICORETTE CQ PATCH 621000050085 O $0* OTC NICORETTE GUM 621000100028 O $0* OTC nicotine gum 621000100028 Y $0* OTC nicotine lozenge 621000100047 Y $0* OTC nicotine patch 621000050085 Y $0* OTC NICOTINE PATCH KIT 621000050064 N $0* OTC NICOTROL INHALER 62100005002410 621000050024 N $0NICOTROL NASAL SPRAY 62100005002020 621000050020 N $0nifedipine cap 34000020000105 340000200001 Y 1nifedipine cap 34000020000110 340000200001 Y 1nifedipine ER tab 34000020007550 340000200075 Y 1nifedipine ER tab 34000020007570 340000200075 Y 1nifedipine ER tab 34000020007575 340000200075 Y 1nifedipine ER tab 34000020007580 340000200075 Y 1nikki 28 day tab 25990002150316 259900021503 Y $0NILANDRON TAB 21402460000330 214024600003 O 2nilutamide tab 21402460000330 214024600003 Y 2nimodipine cap 34000022000120 340000220001 Y 2NIMOTOP CAP 340000220001 O 3*NINLARO CAP 21536045100120 215360451001 N M NM PA_NSONINLARO CAP 21536045100130 215360451001 N M NM PA_NSONINLARO CAP 21536045100140 215360451001 N M NM PA_NSONIPENT INJ 21700045002120 217000450021 O M PA_BvDNIRAVAM TAB 57100010007205 571000100072 O 3NISOLDIPINE SR TAB 34000024007526 340000240075 N 2nisoldipine tab 34000024007508 340000240075 Y 2nisoldipine tab 34000024007517 340000240075 Y 2nisoldipine tab 34000024007520 340000240075 Y 2nisoldipine tab 34000024007530 340000240075 Y 2nisoldipine tab 34000024007535 340000240075 Y 2nisoldipine tab 34000024007540 340000240075 Y 2NITRO-BID OINTMENT 32100030004205 321000300042 N 3NITRO-DUR PATCH 0.1MG, 0.2MG, 0.4MG, 0.6MG 32100030008510 321000300085 O 3NITRO-DUR PATCH 0.1MG, 0.2MG, 0.4MG, 0.6MG 32100030008520 321000300085 O 3NITRO-DUR PATCH 0.1MG, 0.2MG, 0.4MG, 0.6MG 32100030008540 321000300085 O 3NITRO-DUR PATCH 0.1MG, 0.2MG, 0.4MG, 0.6MG 32100030008550 321000300085 O 3NITRO-DUR PATCH 0.3MG, 0.8MG 32100030008530 321000300085 N 2NITRO-DUR PATCH 0.3MG, 0.8MG 32100030008560 321000300085 N 2nitrofurantoin cap 53000050150120 530000501501 Y 1nitrofurantoin macro cap 53000050100110 530000501001 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITnitrofurantoin macro cap 53000050100115 530000501001 Y 1nitrofurantoin macro cap 53000050100120 530000501001 Y 1nitrofurantoin susp 53000050001810 530000500018 Y 2nitroglycerin 0.3mg, 0.4mg, 0.6mg sl tab 32100030000710 321000300007 Y 2nitroglycerin 0.3mg, 0.4mg, 0.6mg sl tab 32100030000715 321000300007 Y 2nitroglycerin 0.3mg, 0.4mg, 0.6mg sl tab 32100030000720 321000300007 Y 2nitroglycerin cap 321000300002 Y 1*nitroglycerin lingual spray 32100030002060 321000300020 Y 2NITROLINGUAL PUMP SPRAY 32100030002060 321000300020 O 3NITROMIST AEROSOL 32100030003460 321000300034 M 3NITROSTAT 0.3MG, 0.4MG, 0.6MG SL TAB 32100030000710 321000300007 O 2NITROSTAT 0.3MG, 0.4MG, 0.6MG SL TAB 32100030000715 321000300007 O 2NITROSTAT 0.3MG, 0.4MG, 0.6MG SL TAB 32100030000720 321000300007 O 2nizatidine cap 49200040000110 492000400001 Y 1nizatidine cap 49200040000120 492000400001 Y 1nizatidine soln 49200040002050 492000400020 Y 2NIZATIDINE SOLN 15MG/ML 49200040002050 492000400020 N 2NIZORAL SHAMPOO 90154045004510 901540450045 O 3NORCO TAB 65991702100305 659917021003 O 3 QLNORCO TAB 65991702100356 659917021003 O 3 QLNORCO TAB 65991702100358 659917021003 O 3 QLNORDITROPIN INJ 30100020002062 301000200020 N 4 ESP NM PANORDITROPIN INJ 00169770311 30100020002066 301000200020 N 4 ESP NM PANORDITROPIN INJ 00169770411 30100020002050 301000200020 N 4 ESP NM PANORDITROPIN INJ 00169770421 30100020002050 301000200020 N 4 ESP NM PANORDITROPIN INJ 00169770511 30100020002056 301000200020 N 4 ESP NM PANORDITROPIN INJ 00169770521 30100020002056 301000200020 N 4 ESP NM PANORDITROPIN INJ 00169776811 30100020002050 301000200020 N 4 ESP NM PAnorethindrone acetate tab 26000030100305 260000301003 Y 1norethindrone acetate/ethinyl estradiol tab 24993002250305 249930022503 Y 2norethindrone/ethinyl estradiol FE chew tab 25990003600540 259900036005 Y $0norethindrone/ethinyl estradiol FE tab 25990003610312 259900036103 Y $0NORINYL TAB 25990002500320 259900025003 O 3NORINYL TAB 25990002700310 259900027003 N 3NORITATE CREAM 90060040003720 900600400037 N 3 STNORMOSOL INJ 79993002872010 799930028720 N M PA_BvDNORMOSOL-M/D5W INJ 79993002752010 799930027520 N M PA_BvDNORMOSOL-R INJ 79992001752000 799920017520 N M PA_BvDnormosol-R inj 79992001772000 799920017720 N M PA_BvDNOROXIN TAB 050000400003 N 3*NORPACE CAP 35100010100105 351000101001 O 3



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITNORPACE CAP 35100010100110 351000101001 O 3NORPACE CR CAP 35100010106910 351000101069 N 2NORPACE CR CAP 35100010106915 351000101069 N 2NORPRAMIN TAB 58200030100305 582000301003 O 3NORPRAMIN TAB 58200030100310 582000301003 O 3NORPRAMIN TAB 58200030100315 582000301003 O 3NORPRAMIN TAB 58200030100320 582000301003 O 3NORPRAMIN TAB 58200030100325 582000301003 O 3NORPRAMIN TAB 58200030100330 582000301003 O 3NOR-QD TAB 25100010000305 251000100003 O 3NORTHERA CAP 38700030000130 387000300001 N M NM PANORTHERA CAP 38700030000140 387000300001 N M NM PANORTHERA CAP 38700030000150 387000300001 N M NM PAnortriptyline cap 58200060100105 582000601001 Y 1nortriptyline cap 58200060100110 582000601001 Y 1nortriptyline cap 58200060100115 582000601001 Y 1nortriptyline cap 58200060100120 582000601001 Y 1NORTRIPTYLINE SOLN 58200060102005 582000601020 N 1NORVASC TAB 34000003100320 340000031003 O 3NORVASC TAB 34000003100330 340000031003 O 3NORVASC TAB 34000003100340 340000031003 O 3NORVIR CAP 12104560000120 121045600001 N 4 ESPNORVIR SOLN 12104560002020 121045600020 N 2NORVIR TAB 12104560000320 121045600003 N 4 ESPnovamine inj 80302010102060 803020101020 Y M PA_BvDNOVOLIN MIX 70/30 VIAL 00169183702 27104090001810 271040900018 N 1 OTCNOVOLIN MIX 70/30 VIAL 00169183711 27104090001810 271040900018 N 1 OTCNOVOLIN N VIAL 00169183402 27104020001805 271040200018 N 1 OTCNOVOLIN N VIAL 00169183411 27104020001805 271040200018 N 1 OTCNOVOLIN R VIAL 00169183302 27104010002005 271040100020 N 1 OTCNOVOLIN R VIAL 00169183311 27104010002005 271040100020 N 1 OTCNOVOLOG FLEXPEN INJ 2710400200D220 2710400200D2 N 1NOVOLOG MIX FLEXPEN INJ 2710407000D320 2710407000D3 N 1NOVOLOG MIX INJ 27104070001820 271040700018 N 1NOVOLOG PENFILL 2710400200E220 2710400200E2 N 1NOVOLOG VIAL 27104002002020 271040020020 N 1NOXAFIL DR TAB 11407060000620 114070600006 N M NM PANOXAFIL SUSP 11407060001820 114070600018 N 2 PANUCORT LOTION 905500751041 N 3*NUCYNTA ER TAB 65100091107420 651000911074 N 2 QLNUCYNTA ER TAB 65100091107430 651000911074 N 2 QL



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITNUCYNTA ER TAB 65100091107440 651000911074 N 2 QLNUCYNTA ER TAB 65100091107450 651000911074 N 2 QLNUCYNTA ER TAB 65100091107460 651000911074 N 2 QLNUCYNTA TAB 50MG 65100091100320 651000911003 N 3 QLNUCYNTA TAB 75MG, 100MG 65100091100330 651000911003 N 3 QLNUCYNTA TAB 75MG, 100MG 65100091100340 651000911003 N 3 QLNUEDEXTA CAP 62609902300120 626099023001 N 2 QLNULOJIX INJ 99408020002120 994080200021 N M NM PA_BvDNUPLAZID TAB 59400028200320 594000282003 N M NM PA_NSONUTROPIN AQ 30100020002020 301000200020 N NCNUTROPIN AQ 30100020002064 301000200020 N NCNUTROPIN INJ 30100020002015 301000200020 N NCNUVARING 25970002309020 259700023090 N $0NUVIGIL TAB 61400010000310 614000100003 O 3 PA QLNUVIGIL TAB 61400010000330 614000100003 O 3 PA QLNUVIGIL TAB 61400010000340 614000100003 O 3 PA QLNUVIGIL/ARMODAFINIL TAB 200MG 61400010000335 614000100003 M 3 PA QLnystatin cream 90150080003710 901500800037 Y 1nystatin ointment 90150080004215 901500800042 Y 1nystatin oral powder 110000600029 Y 1*nystatin powder 90150080002900 901500800029 Y 1nystatin susp 88100010001805 881000100018 Y 1nystatin tab 11000060000305 110000600003 Y 1nystatin/triamcinolone cream 90159902253700 901599022537 Y 2nystatin/triamcinolone ointment 90159902254200 901599022542 Y 2OCTAGAM INJ 19100020102046 191000201020 N M NM PAOCTAGAM INJ 19100020102063 191000201020 N M NM PAoctreotide inj 30170070102005 301700701020 Y 2 PA_BvDoctreotide inj 30170070102010 301700701020 Y 2 PA_BvDoctreotide inj 30170070102015 301700701020 Y 2 PA_BvDoctreotide inj 30170070102020 301700701020 Y 2 PA_BvDoctreotide inj 30170070102030 301700701020 Y 2 PA_BvDOCUFEN OPHTH SOLN 86805020102010 868050201020 O 3OCUFLOX OPHTH DROP 86101047002020 861010470020 O 3ODEFSEY TAB 12109903390320 121099033903 N M NMODOMZO CAP 21370060200120 213700602001 N M NM PA_NSOOFEV CAP 45554050200130 455540502001 N 4 NM PAOFEV CAP 45554050200120 455540502001 N 4 NM PAofloxacin ophth soln 86101047002020 861010470020 Y 1ofloxacin otic soln 87100060002010 871000600020 Y 1OFLOXACIN TAB 05000050000340 050000500003 N 2



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITOGESTREL TAB 25990002900320 259900029003 N 3olanzapine inj 59157060002120 591570600021 Y M PA_BvDolanzapine ODT 59157060007210 591570600072 Y 2olanzapine ODT 59157060007220 591570600072 Y 2olanzapine ODT 59157060007230 591570600072 Y 2olanzapine ODT 59157060007240 591570600072 Y 2olanzapine tab 59157060000305 591570600003 Y 1olanzapine tab 59157060000310 591570600003 Y 1olanzapine tab 59157060000315 591570600003 Y 1olanzapine tab 59157060000320 591570600003 Y 1olanzapine tab 59157060000330 591570600003 Y 1olanzapine tab 59157060000340 591570600003 Y 1olanzapine/fluoxetine cap 62995002500110 629950025001 Y 2olanzapine/fluoxetine cap 62995002500120 629950025001 Y 2olanzapine/fluoxetine cap 62995002500125 629950025001 Y 2olanzapine/fluoxetine cap 62995002500140 629950025001 Y 2olanzapine/fluoxetine cap 62995002500145 629950025001 Y 2OLEPTRO TAB 58120080107520 581200801075 N 3OLEPTRO TAB 58120080107530 581200801075 N 3olmesartan tab 36150055200320 361500552003 Y 3olmesartan tab 36150055200340 361500552003 Y 3olmesartan tab 36150055200360 361500552003 Y 3olmesartan/amlodipine/hydrochlorothiazide tab 36994503450310 369945034503 Y 3olmesartan/amlodipine/hydrochlorothiazide tab 36994503450320 369945034503 Y 3olmesartan/amlodipine/hydrochlorothiazide tab 36994503450330 369945034503 Y 3olmesartan/amlodipine/hydrochlorothiazide tab 36994503450340 369945034503 Y 3olmesartan/amlodipine/hydrochlorothiazide tab 36994503450350 369945034503 Y 3olmesartan/hydrochlorothiazide tab 36994002500320 369940025003 Y 3olmesartan/hydrochlorothiazide tab 36994002500340 369940025003 Y 3olmesartan/hydrochlorothiazide tab 36994002500345 369940025003 Y 3olopatadine nasal spray 424010601020 Y 2*olopatadine nasal spray 0.06% 42401060102020 424010601020 Y 2olopatadine ophth soln 86802065102020 868020651020 Y 2OLUX FOAM 90550025103920 905500251039 O 3omega-3-acid ethyl esters cap 39500045200130 395000452001 Y 2omeprazole cap 49270060006510 492700600065 Y 1omeprazole cap 49270060006520 492700600065 Y 1omeprazole cap 49270060006530 492700600065 Y 1omeprazole/bicarbonate powder pack 499960026030 Y 3*omeprazole/sodium bicarbonate cap 499960026001 Y NCOMNARIS NASAL SPRAY 42200018001820 422000180018 N 3 QL ST



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITOMNIPOD STARTER KIT 972010305064 N NCONCASPAR INJ 21250060002020 212500600020 N M NM PA_BvDondansetron inj 50250065052024 502500650520 Y M PA_BvDondansetron inj 50250065052030 502500650520 Y M PA_BvDondansetron ODT 50250065007220 502500650072 Y 1 PA_BvDondansetron ODT 50250065007240 502500650072 Y 1 PA_BvDondansetron soln 50250065052070 502500650520 Y 1 PA_BvDondansetron tab 50250065050310 502500650503 Y 1 PA_BvDondansetron tab 50250065050320 502500650503 Y 1 PA_BvDondansetron tab 50250065050340 502500650503 Y 1 PA_BvDONETOUCH CALIBRATION LIQUID 53885027202 97202007100920 972020071009 N 20%* OTC PAONETOUCH CALIBRATION LIQUID 53885041601 97202007100900 972020071009 N 20%* PAONETOUCH CALIBRATION LIQUID 53885045802 97202007100900 972020071009 N 20%* OTC PAONETOUCH CALIBRATION LIQUID 57599013801 97202007100900 972020071009 N 20%* OTC PAONETOUCH CALIBRATION LIQUID 57599031201 97202007100900 972020071009 N 20%* PAONEXTON GEL 900599021940 O 3*ONFI SUSP 72100007001830 721000070018 N M PA_NSOONFI TAB 72100007000310 721000070003 N 2 PA_NSOONFI TAB 72100007000320 721000070003 N 2 PA_NSOONGLYZA TAB 27550065100320 275500651003 N 2 QL RXCONGLYZA TAB 27550065100330 275500651003 N 2 QL RXCONSOLIS FILM 65100025108220 651000251082 N NCONSOLIS FILM 65100025108230 651000251082 N NCONSOLIS FILM 65100025108240 651000251082 N NCONSOLIS FILM 65100025108250 651000251082 N NCONSOLIS FILM 65100025108260 651000251082 N NCOPANA ER TAB (CRUSH RESISTANT) 6510008010A705 6510008010A7 N M QLOPANA ER TAB (CRUSH RESISTANT) 6510008010A707 6510008010A7 N M QLOPANA ER TAB (CRUSH RESISTANT) 6510008010A710 6510008010A7 N M QLOPANA ER TAB (CRUSH RESISTANT) 6510008010A715 6510008010A7 N M QLOPANA ER TAB (CRUSH RESISTANT) 6510008010A720 6510008010A7 N M QLOPANA ER TAB (CRUSH RESISTANT) 6510008010A730 6510008010A7 N M QLOPANA ER TAB (CRUSH RESISTANT) 6510008010A740 6510008010A7 N M QLOPANA TAB 65100080100305 651000801003 O M QLOPANA TAB 65100080100310 651000801003 O M QLOPDIVO INJ 21353041002020 213530410020 N M NM PA_NSOopium tincture 471000302015 Y 3*OPSUMIT TAB 40160050000320 401600500003 N 2 NM PAORACIT SOLN 562020200020 N 1*ORAP TAB 1MG, 2MG 62000030000303 620000300003 O 2ORAP TAB 1MG, 2MG 62000030000305 620000300003 O 2



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITORAPRED ODT 22100040207215 221000402072 O 3ORAPRED ODT 22100040207220 221000402072 O 3ORAPRED ODT 22100040207240 221000402072 O 3ORAVIG TAB 881000600003 N 3*ORAVIG TAB 50MG 88100060000310 881000600003 N 3ORENCIA AUTO-INJECTOR 6640001000D520 6640001000D5 N M NM PAORENCIA INJ 66400010002120 664000100021 N M NM PAORENCIA SC INJ 6640001000E520 6640001000E5 N 4 NM PAORFADIN CAP 30904045000110 309040450001 N M NM PAORFADIN CAP 30904045000120 309040450001 N M NM PAORFADIN CAP 30904045000130 309040450001 N M NM PAORFADIN CAP 30904045000140 309040450001 N M NM PAORKAMBI TAB 45309902300310 453099023003 N 4 ESP NM PA QLORKAMBI TAB 45309902300320 453099023003 N 4 ESP NM PA QLorphenadrine citrate inj 75100080102005 751000801020 Y Morphenadrine ER tab 75100080107410 751000801074 Y 1ORTHO TRI-CYCLEN LO TAB 25992002300310 259920023003 O 3ORTHO TRI-CYCLEN TAB 25992002300320 259920023003 O 3ORTHO-CYCLEN TAB 25990002950310 259900029503 O 3ORTHO-EVRA PATCH 25960002508820 259600025088 O 3ORTHO-NOVUM TAB 25992002200310 259920022003 O 3OSMOPREP TAB 46109902120320 461099021203 N 3OTEZLA TAB 66700015000330 667000150003 N 4 NM PA QLOTEZLA TAB STARTER PACK 6670001500B720 6670001500B7 N 4 NM PA QLOVACE CREAM 903000600037 N 3*OVACE PLUS SHAMPOO 903000600045 O 3*OVACE PLUS WASH 903000600040 O 3*OVACE WASH 903000600009 O 3*OVCON 35 TAB 25990002500305 259900025003 O 3OVIDE LOTION 90900030004120 909000300041 O 3oxacillin inj 01300050102115 013000501021 Y M PA_BvDoxacillin inj 01300050102120 013000501021 Y M PA_BvDoxacillin inj 01300050102130 013000501021 Y M PA_BvDoxaliplatin inj 21100028002025 211000280020 Y M PA_BvDoxaliplatin inj 21100028002030 211000280020 Y M PA_BvDOXANDRIN TAB 23200040000305 232000400003 O 3OXANDRIN TAB 23200040000320 232000400003 O 3oxandrolone tab 23200040000305 232000400003 Y 1oxandrolone tab 23200040000320 232000400003 Y 1oxaprozin tab 66100065000320 661000650003 Y 1oxazepam cap 57100070000105 571000700001 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDIToxazepam cap 57100070000110 571000700001 Y 1oxazepam cap 57100070000115 571000700001 Y 1oxcarbazepine susp 72600046001820 726000460018 Y 1oxcarbazepine tab 72600046000310 726000460003 Y 1oxcarbazepine tab 72600046000320 726000460003 Y 1oxcarbazepine tab 72600046000340 726000460003 Y 1oxiconazole nitrate cream 90154065003710 901540650037 Y 2OXISTAT CREAM 90154065003710 901540650037 O 2OXISTAT LOTION 90154065004120 901540650041 N 2OXSORALEN LOTION 90871010004105 908710100041 N MOXSORALEN ULTRA CAP 90250560100110 902505601001 O 3OXTELLAR XR TAB 72600046007520 726000460075 N MOXTELLAR XR TAB 72600046007530 726000460075 N MOXTELLAR XR TAB 72600046007540 726000460075 N Moxybutynin ER tab 54100045207520 541000452075 Y 2oxybutynin ER tab 54100045207530 541000452075 Y 2oxybutynin ER tab 54100045207540 541000452075 Y 2oxybutynin syrup 54100045201220 541000452012 Y 1oxybutynin tab 54100045200330 541000452003 Y 1oxycodone cap 65100075100110 651000751001 Y 1 QLOXYCODONE ER TAB 00093573101 6510007510A710 6510007510A7 M NCOXYCODONE ER TAB 00093573201 6510007510A720 6510007510A7 M NCOXYCODONE ER TAB 00093573301 6510007510A740 6510007510A7 M NCOXYCODONE ER TAB 00093573401 6510007510A780 6510007510A7 M NCOXYCODONE ER TAB 00115155601 6510007510A710 6510007510A7 M NCOXYCODONE ER TAB 00115155701 6510007510A715 6510007510A7 M NCOXYCODONE ER TAB 00115155801 6510007510A720 6510007510A7 M NCOXYCODONE ER TAB 00115155901 6510007510A730 6510007510A7 M NCOXYCODONE ER TAB 00115156001 6510007510A740 6510007510A7 M NCOXYCODONE ER TAB 00115156101 6510007510A760 6510007510A7 M NCOXYCODONE ER TAB 00115156201 6510007510A780 6510007510A7 M NCOXYCODONE ER TAB 55700033430 6510007510A710 6510007510A7 M NCOXYCODONE ER TAB 55700044330 6510007510A740 6510007510A7 M NCOXYCODONE ER TAB 00591269301 6510007510A740 6510007510A7 M NCOXYCODONE ER TAB 00591270801 6510007510A780 6510007510A7 M NCOXYCODONE ER TAB 00781570301 6510007510A710 6510007510A7 M NCOXYCODONE ER TAB 00781572601 6510007510A720 6510007510A7 M NCOXYCODONE ER TAB 00781576701 6510007510A740 6510007510A7 M NCOXYCODONE ER TAB 00781578501 6510007510A780 6510007510A7 M NCOXYCODONE ER TAB 49884013601 6510007510A710 6510007510A7 M NCOXYCODONE ER TAB 49884013701 6510007510A720 6510007510A7 M NC



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITOXYCODONE ER TAB 49884013801 6510007510A740 6510007510A7 M NCOXYCODONE ER TAB 49884019701 6510007510A780 6510007510A7 M NCOXYCODONE ER TAB 63304068301 6510007510A740 6510007510A7 M NCOXYCODONE ER TAB 63304068401 6510007510A780 6510007510A7 M NCoxycodone oral soln 20mg/ml 65100075101320 651000751013 Y 2 QLoxycodone oral soln 5mg/5ml 65100075102005 651000751020 Y 2 QLoxycodone tab 10mg, 15mg, 20mg, 30mg 65100075100320 651000751003 Y 1 QLoxycodone tab 10mg, 15mg, 20mg, 30mg 65100075100325 651000751003 Y 1 QLoxycodone tab 10mg, 15mg, 20mg, 30mg 65100075100330 651000751003 Y 1 QLoxycodone tab 10mg, 15mg, 20mg, 30mg 65100075100340 651000751003 Y 1 QLoxycodone tab 5mg 65100075100310 651000751003 Y 1 QLOXYCODONE/ACETAMINOPHEN SOLN 5-325MG/5ML 65990002202005 659900022020 N 2 QLoxycodone/acetaminophen tab 65990002200305 659900022003 Y 1 QLoxycodone/acetaminophen tab 65990002200310 659900022003 Y 1 QLoxycodone/acetaminophen tab 65990002200327 659900022003 Y 1 QLoxycodone/acetaminophen tab 65990002200335 659900022003 Y 1 QLoxycodone/aspirin tab 65990002220340 659900022203 Y 1 QLOXYCODONE/IBUPROFEN TAB 65990002260320 659900022603 N 2 QLoxycodone/ibuprofen tab 65990002260320 659900022603 Y 2 QLOXYCONTIN CR TAB 6510007510A710 6510007510A7 M 2 QLOXYCONTIN CR TAB 6510007510A715 6510007510A7 M 2 QLOXYCONTIN CR TAB 6510007510A720 6510007510A7 M 2 QLOXYCONTIN CR TAB 6510007510A730 6510007510A7 M 2 QLOXYCONTIN CR TAB 6510007510A740 6510007510A7 M 2 QLOXYCONTIN CR TAB 6510007510A760 6510007510A7 M 2 QLOXYCONTIN CR TAB 80MG 6510007510A780 6510007510A7 M 2 QLoxymorphone ER tab 65100080107405 651000801074 Y 2 QLoxymorphone ER tab 65100080107407 651000801074 Y 2 QLoxymorphone ER tab 65100080107410 651000801074 Y 2 QLoxymorphone ER tab 65100080107415 651000801074 Y 2 QLoxymorphone ER tab 65100080107420 651000801074 Y 2 QLoxymorphone ER tab 65100080107430 651000801074 Y 2 QLoxymorphone ER tab 65100080107440 651000801074 Y 2 QLoxymorphone tab 65100080100305 651000801003 Y M QLoxymorphone tab 65100080100310 651000801003 Y M QLOXYTROL PATCH 54100045008720 541000450087 N 3 STpaclitaxel inj 21500012001325 215000120013 Y M PA_BvDpaclitaxel inj 21500012001335 215000120013 Y M PA_BvDpaclitaxel inj 21500012001350 215000120013 Y M PA_BvDpaliperidone SR tab 59070050007505 590700500075 Y 2 PA_NSOpaliperidone SR tab 59070050007510 590700500075 Y 2 PA_NSO



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITpaliperidone SR tab 59070050007520 590700500075 Y 2 PA_NSOpaliperidone SR tab 59070050007530 590700500075 Y 2 PA_NSOPAMELOR CAP 58200060100105 582000601001 O 3PAMELOR CAP 58200060100110 582000601001 O 3PAMELOR CAP 58200060100115 582000601001 O 3PAMELOR CAP 58200060100120 582000601001 O 3pamidronate disodium inj 30042060102006 300420601020 Y M PA_BvDpamidronate disodium inj 30042060102012 300420601020 Y M PA_BvDpamidronate disodium inj 30042060102120 300420601021 Y M PA_BvDpamidronate disodium inj 30042060102140 300420601021 Y M PA_BvDPAMIDRONATE INJ 6MG/ML 30042060102009 300420601020 N M PA_BvDPAMINE FORTE TAB 49102060100320 491020601003 O 3PAMINE TAB 49102060100305 491020601003 O 3PANATUSS PEDIATRIC LIQUID 439980043909 N 3* OTCPANCREAZE CAP 51200024006704 512000240067 N 3 STPANCREAZE CAP 51200024006710 512000240067 N 3 STPANCREAZE CAP 51200024006734 512000240067 N 3 STPANCREAZE CAP 51200024006750 512000240067 N 3 STPANCREAZE CAP 51200024006754 512000240067 N 3 STPANDEL CREAM 90550075273720 905500752737 N 3PANRETIN GEL 90376015004020 903760150040 N M NMpantoprazole inj 49270070102120 492700701021 Y Mpantoprazole tab 49270070100610 492700701006 Y 1pantoprazole tab 49270070100620 492700701006 Y 1PARAFON FORT TAB 75100040000310 751000400003 O 3PARAGARD IUD 250500100053 N $0*parcaine ophth soln 86750020102005 867500201020 Y 1paricalcitol cap 30905070000110 309050700001 Y 2 PA_BvDparicalcitol cap 30905070000120 309050700001 Y 2 PA_BvDparicalcitol cap 30905070000140 309050700001 Y 2 PA_BvDparicalcitol inj 30905070002010 309050700020 Y M PA_BvDparicalcitol inj 30905070002020 309050700020 Y M PA_BvDPARLODEL CAP 73200020100105 732000201001 O 3PARNATE TAB 58100030100305 581000301003 O 3paromomycin cap 07000055100110 070000551001 Y 2paroxetine ER tab 58160060007520 581600600075 Y 2paroxetine ER tab 58160060007530 581600600075 Y 2paroxetine ER tab 58160060007540 581600600075 Y 2PAROXETINE ORAL SUSP 58160060001820 581600600018 N 3paroxetine tab 58160060000310 581600600003 Y 1paroxetine tab 58160060000320 581600600003 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITparoxetine tab 58160060000330 581600600003 Y 1paroxetine tab 58160060000340 581600600003 Y 1PASER GRANULE 09000010003020 090000100030 N MPATADAY OPHTH SOLN 86802065102030 868020651020 N 2PATANASE NASAL SPRAY 42401060102020 424010601020 O 2PATANOL OPHTH SOLN 86802065102020 868020651020 O 3PAXIL CR TAB 58160060007520 581600600075 O 3PAXIL CR TAB 58160060007530 581600600075 O 3PAXIL CR TAB 58160060007540 581600600075 O 3PAXIL TAB 58160060000310 581600600003 O 3PAXIL TAB 58160060000320 581600600003 O 3PAXIL TAB 58160060000330 581600600003 O 3PAXIL TAB 58160060000340 581600600003 O 3PCE EC TAB 03100006000605 031000060006 N 3PCE EC TAB 03100006000610 031000060006 N 3PEAK FLOW METER 971015300062 N 20%* OTCPEDIAPRED SOLN 22100040202040 221000402020 O 3PEDIARIX INJ 18990005501820 189900055018 N $0 PA_BvDPEDIATEX TDM SUSP 439958033818 N 3*pediatric multiple vitamins/fluoride chew tab 784410000005 Y 3*pediatric multiple vitamins/fluoride soln 784405000020 Y 1*pediatric multiple vitamins/fluoride soln 784410000020 Y 1*pediatric multiple vitamins/fluoride/iron soln 784500000020 Y 1*PEDVAX HIB INJ 17200030101820 172000301018 N $0PEGANONE TAB 72200010000310 722000100003 N 2PEGASYS PROCLICK INJ 12353060052020 123530600520 N 4 ESP NMPEGASYS PROCLICK INJ 12353060052030 123530600520 N 4 ESP NMPEGASYS PROCLICK INJ 12353060052040 123530600520 N 4 ESP NMPEG-INTRON KIT 12353060106410 123530601064 N 4 ESP NMPEG-INTRON KIT 12353060106416 123530601064 N 4 ESP NMPEG-INTRON KIT 12353060106424 123530601064 N 4 ESP NMPEG-INTRON KIT 12353060106430 123530601064 N 4 ESP NMPEN NEEDLE 97051050146318 970510501463 N 20% OTCPEN NEEDLE 97051050146322 970510501463 N 20% OTCPEN NEEDLE 97051050146330 970510501463 N 20% OTCPEN NEEDLE 97051050146331 970510501463 N 20% OTCPEN NEEDLE 97051050146340 970510501463 N 20% OTCPEN NEEDLE 97051050146344 970510501463 N 20% OTCPEN NEEDLE 97051050146358 970510501463 N 20% OTCPEN NEEDLE 97051050146361 970510501463 N 20% OTCPEN NEEDLE 97051050146364 970510501463 N 20% OTC



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITPEN NEEDLE 97051050146366 970510501463 N 20% OTCPEN NEEDLE 97051050146367 970510501463 N 20% OTCPEN NEEDLE 97051050146368 970510501463 N 20% OTCPEN NEEDLE 97051050146372 970510501463 N 20% OTCPEN NEEDLE 97051050146377 970510501463 N 20% OTCPEN NEEDLE 97051050146378 970510501463 N 20% OTCPEN NEEDLE 97051050146380 970510501463 N 20% OTCPENICILLIN G PROCAINE INJ 01100030001820 011000300018 N M PA_BvDPENICILLIN G SODIUM INJ 01100010202105 011000102021 N M PA_BvDpenicillin gk inj 01100010102125 011000101021 Y M PA_BvDpenicillin gk inj 01100010102135 011000101021 Y M PA_BvDPENICILLIN GK/DEXTROSE INJ 01100010112060 011000101120 N M PA_BvDPENICILLIN GK/DEXTROSE INJ 01100010112070 011000101120 N M PA_BvDpenicillin vk soln 01100040102105 011000401021 Y 1penicillin vk soln 01100040102110 011000401021 Y 1penicillin vk tab 01100040100310 011000401003 Y 1penicillin vk tab 01100040100315 011000401003 Y 1PENNSAID SOLN 1.5%, 2% 90210030302025 902100303020 O 3PENNSAID SOLN 1.5%, 2% 90210030302030 902100303020 N 3PENTAM INJ 16000045002130 160000450021 N 2 PA_BvDPENTASA CR CAP 52500030000210 525000300002 N 3 STPENTASA CR CAP 52500030000220 525000300002 N 3 STpentazocine/naloxone tab 65200040300310 652000403003 Y 2 QLPENTOSTATIN INJ 21700045002120 217000450021 N M NM PA_BvDpentoxifylline ER tab 85200010000410 852000100004 Y 1PEPCID SUSP 49200030001920 492000300019 O 2PEPCID TAB 49200030000320 492000300003 O 3PEPCID TAB 49200030000340 492000300003 O 3PERCOCET TAB 65990002200305 659900022003 O 3 QLPERCOCET TAB 65990002200310 659900022003 O 3 QLPERCOCET TAB 65990002200327 659900022003 O 3 QLPERCOCET TAB 65990002200335 659900022003 O 3 QLPERFOROMIST NEB 44201027102520 442010271025 N 3 PA_BvDPERIDEX SOLN 881500201020 O 3*perindopril tab 36100035100310 361000351003 Y 1perindopril tab 36100035100320 361000351003 Y 1perindopril tab 36100035100330 361000351003 Y 1periogard soln 88150020102012 881500201020 Y 1PERJETA INJ 21353054002020 213530540020 N M NM PA_NSOpermethrin cream 90900035003720 909000350037 Y 1perphenazine tab 59200045000305 592000450003 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITperphenazine tab 59200045000310 592000450003 Y 1perphenazine tab 59200045000315 592000450003 Y 1perphenazine tab 59200045000320 592000450003 Y 1PERPHENAZINE/AMITRIPTYLINE TAB 62994002600310 629940026003 N 1PERPHENAZINE/AMITRIPTYLINE TAB 62994002600315 629940026003 N 1PERPHENAZINE/AMITRIPTYLINE TAB 62994002600320 629940026003 N 1PERPHENAZINE/AMITRIPTYLINE TAB 62994002600325 629940026003 N 1PERPHENAZINE/AMITRIPTYLINE TAB 62994002600330 629940026003 N 1PERSANTINE TAB 85150030000310 851500300003 O 3PERSANTINE TAB 85150030000320 851500300003 O 3PERSANTINE TAB 85150030000330 851500300003 O 3PERTZYE CAP 51200024006725 512000240067 N 3 STPERTZYE CAP 51200024006749 512000240067 N 3 STPEXEVA TAB 58160060300310 581600603003 N 3 ST ST_NSOPEXEVA TAB 58160060300320 581600603003 N 3 ST ST_NSOPEXEVA TAB 58160060300330 581600603003 N 3 ST ST_NSOPEXEVA TAB 58160060300340 581600603003 N 3 ST ST_NSOPFIZERPEN G INJ 01100010102125 011000101021 O M PA_BvDPFIZERPEN G INJ 01100010102135 011000101021 O M PA_BvDphenazopyridine tab 563000101003 Y 1*phenelzine tab 58100020100305 581000201003 Y 1PHENERGAN INJ 41400020102005 414000201020 O MPHENERGAN INJ 41400020102010 414000201020 O Mphenobarbital elixir 60100060001010 601000600010 Y 1PHENOBARBITAL TAB 15MG, 30MG, 60MG, 100MG 60100060000305 601000600003 N 1PHENOBARBITAL TAB 15MG, 30MG, 60MG, 100MG 60100060000315 601000600003 N 1PHENOBARBITAL TAB 15MG, 30MG, 60MG, 100MG 60100060000320 601000600003 N 1PHENOBARBITAL TAB 15MG, 30MG, 60MG, 100MG 60100060000325 601000600003 N 1phenobarbital tab 16.2mg, 32.4mg, 64.8mg, 97.2mg 60100060000308 601000600003 Y 1phenobarbital tab 16.2mg, 32.4mg, 64.8mg, 97.2mg 60100060000317 601000600003 Y 1phenobarbital tab 16.2mg, 32.4mg, 64.8mg, 97.2mg 60100060000322 601000600003 Y 1phenobarbital tab 16.2mg, 32.4mg, 64.8mg, 97.2mg 60100060000324 601000600003 Y 1phenoxybenzamine cap 36300010100105 363000101001 Y 2phenylephrine ophth soln 864000401020 Y 1*phenylephrine/guaifenesin tab 439962021003 Y 3* OTCPHENYLEPHRINE-GUAIFENESIN LIQD 5-100 MG/5ML 439962021009 N 3* OTCPHENYLHIST LIQUID 439953032009 N 3* OTCPHENYTEK CAP 72200030200120 722000302001 O 1PHENYTEK CAP 72200030200130 722000302001 O 1phenytoin chew tab 72200030000505 722000300005 Y 2phenytoin EX cap 72200030200110 722000302001 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITphenytoin EX cap 72200030200120 722000302001 Y 1phenytoin EX cap 72200030200130 722000302001 Y 1phenytoin inj 72200030052005 722000300520 Y M PA_BvDphenytoin susp 72200030001810 722000300018 Y 1PHISOHEX LIQUID 921000400009 N 3*PHOSLO CAP 667MG 52800020100120 528000201001 O 3PHOSLYRA SOLN 52800020102020 528000201020 N 2phospha 250 neutral tab 796000301003 Y 1*PHOSPHOLINE OPHTH SOLN 86502020102115 865020201021 N 2PHOTOFRIN INJ 21707070102140 217070701021 N M PA_BvDphysiosol irrigation soln 99750000002000 997500000020 Y M PA_BvDPICATO GEL 0.015% 90378035204020 903780352040 N 3 NM QLPICATO GEL 0.05% 90378035204040 903780352040 N 3 NM QLpilocarpine ophth soln 86501030102015 865010301020 Y 1pilocarpine ophth soln 86501030102020 865010301020 Y 1pilocarpine ophth soln 86501030102030 865010301020 Y 1pilocarpine tab 88501560100310 885015601003 Y 1pilocarpine tab 88501560100320 885015601003 Y 1pimozide tab 1mg, 2mg 62000030000303 620000300003 Y 2pimozide tab 1mg, 2mg 62000030000305 620000300003 Y 2pindolol tab 33100030000305 331000300003 Y 1pindolol tab 33100030000310 331000300003 Y 1pioglitazone tab 27607050100320 276070501003 Y 1pioglitazone tab 27607050100330 276070501003 Y 1pioglitazone tab 27607050100340 276070501003 Y 1pioglitazone/glimepiride tab 27997802400320 279978024003 Y 2pioglitazone/glimepiride tab 27997802400340 279978024003 Y 2pioglitazone/metformin tab 27998002400320 279980024003 Y 2pioglitazone/metformin tab 27998002400340 279980024003 Y 2piperacillin/tazobactam inj 01990002702120 019900027021 Y M PA_BvDpiperacillin/tazobactam inj 01990002702130 019900027021 Y M PA_BvDpiperacillin/tazobactam inj 01990002702140 019900027021 Y M PA_BvDpiperacillin/tazobactam inj 01990002702170 019900027021 Y M PA_BvDpiroxicam cap 66100070000105 661000700001 Y 1piroxicam cap 66100070000110 661000700001 Y 1PLAN B 25400040000320 254000400003 O NCPLAN B 25400040000340 254000400003 O NCPLAQUENIL TAB 13000020100305 130000201003 O 3PLASMA-LYTE INJ 79992001502000 799920015020 N M PA_BvDPLASMA-LYTE/ D5W INJ 79993002402010 799930024020 N M PA_BvDPLASMA-LYTE-A INJ 79992001602000 799920016020 N M PA_BvD



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITPLAVIX TAB 75MG 85158020100320 851580201003 O 3PLEGRIDY PEN INJ 6240307530D2 N 4* ESPPLETAL TAB 85155516000320 851555160003 O 3PLETAL TAB 85155516000330 851555160003 O 3PLEXION SCT CREAM 900599032037 O 3*podofilox soln 90750015002020 907500150020 Y 2polyethylene glycol bulk powder 3350 46600033002910 466000330029 Y Mpolymyxin B inj 16100010102105 161000101021 Y M PA_BvDPOLYTRIM OPHTH SOLN 86109902602020 861099026020 O 3POMALYST CAP 21450080000110 214500800001 N M NM PA_NSOPOMALYST CAP 21450080000115 214500800001 N M NM PA_NSOPOMALYST CAP 21450080000120 214500800001 N M NM PA_NSOPOMALYST CAP 21450080000125 214500800001 N M NM PA_NSOPONSTEL CAP 66100050000105 661000500001 O 3POTABA CAP 771070101001 N 3*potassium bicarbonate effer tab 797000200008 Y 1*potassium chloride effer tab 797099021008 Y 1*potassium chloride ER cap 79700030000205 797000300002 Y 1potassium chloride ER cap 79700030000210 797000300002 Y 1potassium chloride ER tab 79700030000420 797000300004 Y 1potassium chloride ER tab 79700030000430 797000300004 Y 1potassium chloride ER tab 79700030100430 797000301004 Y 1POTASSIUM CHLORIDE ER TAB 8MEQ, 20MEQ 79700030000420 797000300004 M 1POTASSIUM CHLORIDE ER TAB 8MEQ, 20MEQ 79700030000445 797000300004 M 1potassium chloride inj 79700030002005 797000300020 Y M PA_BvDpotassium chloride inj 79700030002050 797000300020 Y M PA_BvDpotassium chloride inj 79700030002055 797000300020 N M PA_BvDpotassium chloride inj 79700030002060 797000300020 Y M PA_BvDpotassium chloride inj 79700030002070 797000300020 Y M PA_BvDpotassium chloride inj 79700030002075 797000300020 Y M PA_BvDpotassium chloride liquid 79700030002085 797000300020 Y 1potassium chloride liquid 79700030002095 797000300020 Y 1potassium chloride powder packet 797000300030 Y 1*POTASSIUM CITRATE CR TAB 56202010200420 562020102004 Y 2POTASSIUM CITRATE CR TAB 56202010200440 562020102004 Y 2potassium citrate CR tab 56202010200460 562020102004 Y 2potassium citrate/citric acid granule 562020220030 Y 1*potassium citrate/citric acid soln 562020220020 Y 1*POTIGA TAB 72600026000320 726000260003 N 2 PA_NSO QLPOTIGA TAB 72600026000330 726000260003 N 2 PA_NSO QLPOTIGA TAB 72600026000340 726000260003 N 2 PA_NSO QL



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITPOTIGA TAB 72600026000350 726000260003 N 2 PA_NSO QLPRADAXA CAP 83337030200120 833370302001 N 2PRADAXA CAP 83337030200130 833370302001 N 2PRADAXA CAP 83337030200140 833370302001 N 2pramipexole ER tab 73203060107520 732030601075 Y 2pramipexole ER tab 73203060107530 732030601075 Y 2pramipexole ER tab 73203060107540 732030601075 Y 2pramipexole ER tab 73203060107545 732030601075 Y 2pramipexole ER tab 73203060107550 732030601075 Y 2pramipexole ER tab 73203060107555 732030601075 Y 2pramipexole ER tab 73203060107560 732030601075 Y 2pramipexole tab 73203060100305 732030601003 Y 1pramipexole tab 73203060100310 732030601003 Y 1pramipexole tab 73203060100315 732030601003 Y 1pramipexole tab 73203060100317 732030601003 Y 1pramipexole tab 73203060100320 732030601003 Y 1pramipexole tab 73203060100330 732030601003 Y 1PRAMOSONE LOTION 905598024041 N 3*PRANDIMET TAB 27995002700320 279950027003 O 3PRANDIMET TAB 27995002700330 279950027003 O 3PRANDIN TAB 27280060000310 272800600003 O 3PRANDIN TAB 27280060000320 272800600003 O 3PRANDIN TAB 27280060000330 272800600003 O 3PRAVACHOL TAB 39400065100330 394000651003 O 3PRAVACHOL TAB 39400065100340 394000651003 O 3PRAVACHOL TAB 39400065100360 394000651003 O 3pravastatin tab 39400065100320 394000651003 Y 1pravastatin tab 39400065100330 394000651003 Y 1pravastatin tab 39400065100340 394000651003 Y 1pravastatin tab 39400065100360 394000651003 Y 1prazosin cap 36202030100105 362020301001 Y 1prazosin cap 36202030100110 362020301001 Y 1prazosin cap 36202030100115 362020301001 Y 1PRECISION CALIBRATION LIQUID 57599013901 97202007100900 972020071009 N 20%* OTCPRECISION CALIBRATION LIQUID 57599741102 97202007100900 972020071009 N 20%* OTCPRECISION CALIBRATION LIQUID 57599843601 97202007100900 972020071009 N 20%* OTCPRECISION CALIBRATION LIQUID 57599912101 97202007100900 972020071009 N 20%* OTCPRECISION SOFT-TACT METER 57599034001 97202010006200 972020100062 N $0* OTCPRECISION XTRA METER 57599051201 97202010006400 972020100064 N $0* OTCPRECISION XTRA METER 57599881401 97202010006200 972020100062 N $0* OTCPRECISION XTRA METER 57599969301 97202010006200 972020100062 N $0* OTC



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITPRECISION XTRA METER 57599983701 97202010006200 972020100062 N $0* OTCPRECISION XTRA TEST STRIP 57599972804 94100030006100 941000300061 N 20%* OTCPRECISION XTRA TEST STRIP 57599987705 94100030006100 941000300061 N 20%* OTCPRECISION XTRA TEST STRIP 57599998705 94100030006100 941000300061 N NC OTCPRECOSE TAB 27500010000310 275000100003 O 3PRECOSE TAB 27500010000320 275000100003 O 3PRECOSE TAB 27500010000340 275000100003 O 3PRED FORTE OPHTH SUSP 1% 86300050101815 863000501018 O 3PRED MILD OPHTH SUSP 86300050101809 863000501018 N 2PRED-G OPHTH SUSP 86309902151810 863099021518 N 2PRED-G S.O.P OPHTH OINTMENT 86309902154210 863099021542 N Mprednicarbate cream 90550083003710 905500830037 Y 1prednicarbate ointment 90550083004210 905500830042 Y 1prednisolone ODT 22100040207220 221000402072 Y 2prednisolone ODT 22100040207215 221000402072 Y 2prednisolone ODT 22100040207240 221000402072 Y 2prednisolone ophth susp 86300050101815 863000501018 Y 1PREDNISOLONE ORAL SOLN 22100040202025 221000402020 N 3PREDNISOLONE SODIUM PHOSPHATE OPHTH SOLN 1% 86300050202015 863000502020 N 2prednisolone sodium phosphate oral soln 22100040202020 221000402020 Y 1prednisolone sodium phosphate oral soln 22100040202040 221000402020 Y 1prednisolone syrup 221000400012 Y 1*PREDNISONE CONC 22100045001310 221000450013 N MPREDNISONE SOLN 22100045002005 221000450020 N 1prednisone tab 22100045000305 221000450003 Y 1prednisone tab 22100045000310 221000450003 Y 1prednisone tab 22100045000315 221000450003 Y 1prednisone tab 22100045000320 221000450003 Y 1prednisone tab 22100045000325 221000450003 Y 1PREDNISONE TAB 22100045000335 221000450003 N 1PREDNISONE TAB 10MG DOSE PACK 2210004500B720 2210004500B7 N 2PREDNISONE TAB 10MG DOSE PACK 2210004500B725 2210004500B7 N 2PREDNISONE TAB DOSE PACK 5MG 2210004500B705 2210004500B7 N 2PREDNISONE TAB DOSE PACK 5MG 2210004500B710 2210004500B7 N 2PREFEST TAB 24993002650320 249930026503 N 3PREMARIN INJ 24000015002110 240000150021 N M PA_BvDPREMARIN TAB 24000015000310 240000150003 N 2PREMARIN TAB 24000015000315 240000150003 N 2PREMARIN TAB 24000015000320 240000150003 N 2PREMARIN TAB 24000015000325 240000150003 N 2PREMARIN TAB 24000015000330 240000150003 N 2



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITPREMARIN VAGINAL CREAM 55350025003710 553500250037 N 2premasol inj 80302010102019 803020101020 Y M PA_BvDPREMPHASE TAB 24993002040370 249930020403 N 2PREMPRO TAB 24993002040340 249930020403 N 2PREMPRO TAB 24993002040345 249930020403 N 2PREMPRO TAB 24993002040350 249930020403 N 2PREMPRO TAB 24993002040360 249930020403 N 2PRENATAL VITAMIN (RX ONLY) 78510018000520 785100180005 N 3PRENATAL VITAMIN (RX ONLY) 78510025000320 785100250003 N 3PRENATAL VITAMIN (RX ONLY) 78510035000320 785100350003 N 3PRENATAL VITAMIN (RX ONLY) 78510530000530 785105300005 N 3PRENATAL VITAMIN (RX ONLY) 78512006000520 785120060005 N 3PRENATAL VITAMIN (RX ONLY) 78512007000120 785120070001 N 3PRENATAL VITAMIN (RX ONLY) 78512012000330 785120120003 N 3PRENATAL VITAMIN (RX ONLY) 78512013000140 785120130001 N 3PRENATAL VITAMIN (RX ONLY) 78512022000315 785120220003 N 3PRENATAL VITAMIN (RX ONLY) 78512032000530 785120320005 N 3PRENATAL VITAMIN (RX ONLY) 78512047000525 785120470005 N 3PRENATAL VITAMIN (RX ONLY) 78512050000162 785120500001 N 3PRENATAL VITAMIN (RX ONLY) 78512050000530 785120500005 N 3PRENATAL VITAMIN (RX ONLY) 78512050200320 785120502003 N 3PRENATAL VITAMIN (RX ONLY) 78512052000329 785120520003 N 3PRENATAL VITAMIN (RX ONLY) 78512060000310 785120600003 N 3PRENATAL VITAMIN (RX ONLY) 78512066000340 785120660003 N 3PRENATAL VITAMIN (RX ONLY) 78512067006340 785120670063 N 3PRENATAL VITAMIN (RX ONLY) 78512071006320 785120710063 N 3PRENATAL VITAMIN (RX ONLY) 78512072000135 785120720001 N 3PRENATAL VITAMIN (RX ONLY) 78512073000140 785120730001 N 3PRENATAL VITAMIN (RX ONLY) 78512076000130 785120760001 N 3PRENATAL VITAMIN (RX ONLY) 78512077006325 785120770063 N 3PRENATAL VITAMIN (RX ONLY) 78512079000230 785120790002 N 3PRENATAL VITAMIN (RX ONLY) 78512090000335 785120900003 N 3PRENATAL VITAMIN (RX ONLY) 78512090000345 785120900003 N 3PRENATAL VITAMIN (RX ONLY) 78512097006316 785120970063 N 3PRENATAL VITAMIN (RX ONLY) 78512097006318 785120970063 N 3PRENATAL VITAMIN (RX ONLY) 78512097006331 785120970063 N 3PRENATAL VITAMIN (RX ONLY) 78515031006320 785150310063 N 3PRENATAL VITAMIN (RX ONLY) 78516014000120 785160140001 N 3PRENATAL VITAMIN (RX ONLY) 78516020006319 785160200063 N 3PRENATAL VITAMIN (RX ONLY) 78516023000130 785160230001 N 3PRENATAL VITAMIN (RX ONLY) 78516023000135 785160230001 N 3



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITPRENATAL VITAMIN (RX ONLY) 78516023000140 785160230001 N 3PRENATAL VITAMIN (RX ONLY) 78516024000127 785160240001 N 3PRENATAL VITAMIN (RX ONLY) 78516024000135 785160240001 N 3PRENATAL VITAMIN (RX ONLY) 78516024000137 785160240001 N 3PRENATAL VITAMIN (RX ONLY) 78516024000140 785160240001 N 3PRENATAL VITAMIN (RX ONLY) 78516025000115 785160250001 N 3PRENATAL VITAMIN (RX ONLY) 78516025000125 785160250001 N 3PRENATAL VITAMIN (RX ONLY) 78516032000130 785160320001 N 3PRENATAL VITAMIN (RX ONLY) 78516035000133 785160350001 N 3PRENATAL VITAMIN (RX ONLY) 78516035000135 785160350001 N 3PRENATAL VITAMIN (RX ONLY) 78516042000125 785160420001 N 3PRENATAL VITAMIN (RX ONLY) 78516047000130 785160470001 N 3PRENATAL VITAMIN (RX ONLY) 78516050000130 785160500001 N 3PRENATAL VITAMIN (RX ONLY) 78516058000130 785160580001 N 3PRENATAL VITAMIN (RX ONLY) 78516060000145 785160600001 N 3PRENATAL VITAMIN (RX ONLY) 78516069006340 785160690063 N 3PRENATAL VITAMIN (RX ONLY) 78516070006335 785160700063 N 3

PRENATAL VITAMINS (PRENATAL PLUS/ PREPLUS/PRENAPLUS) 78512015000324 785120150003 N 2

PRENATAL VITAMINS (PRENATAL PLUS/ PREPLUS/PRENAPLUS) 78516020000130 785160200001 N 2PREVACID 24HOUR CAP (OTC) 492700400065 N 1* OTCPREVACID SOLUTAB 49270040007215 492700400072 N 2PREVACID SOLUTAB 49270040007230 492700400072 N 2PREVIDENT 5000 BOOSTER PASTE 884020200044 O 2*PREVIDENT 5000 DRY MOUTH GEL 884020200040 O 2*PREVIDENT RINSE 884020200020 O 2*previfem tab 25990002950310 259900029503 Y $0PREVPAC THERAPY PACK 49993003206320 499930032063 O 3PREZCOBIX TAB 12109902270320 121099022703 N 4 NMPREZISTA SUSP 12104520101820 121045201018 N 2PREZISTA TAB 600MG, 800MG 12104520100340 121045201003 N 4 ESP NMPREZISTA TAB 600MG, 800MG 12104520100350 121045201003 N 4 ESP NMPREZISTA TAB 75MG, 150MG 12104520100310 121045201003 N 2PREZISTA TAB 75MG, 150MG 12104520100315 121045201003 N 2PRIFTIN TAB 09000085000320 090000850003 N 2PRIMAQUINE TAB 13000030100310 130000301003 N 2PRIMAXIN INJ 16159902402110 161599024021 O M PA_BvDPRIMAXIN INJ 16159902402120 161599024021 O M PA_BvDprimidone tab 72600060000305 726000600003 Y 1primidone tab 72600060000310 726000600003 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITPRIMLEV TAB 65990002200308 659900022003 N 3 QLPRIMLEV TAB 65990002200325 659900022003 N 3 QLPRIMLEV TAB 65990002200333 659900022003 N 3 QLPRIMSOL SOLN 16000055102020 160000551020 N 3PRINIVIL TAB 36100030000303 361000300003 O 3PRINIVIL TAB 36100030000305 361000300003 O 3PRINIVIL TAB 36100030000310 361000300003 O 3PRINIVIL TAB 36100030000315 361000300003 O 3PRINIVIL TAB 36100030000324 361000300003 O 3PRINIVIL TAB 36100030000330 361000300003 O 3PRINIVIL TAB 36991802550320 369918025503 O 3PRINZIDE TAB 36991802550305 369918025503 O 3PRINZIDE TAB 36991802550310 369918025503 O 3PRISTIQ TAB 58180020207510 581800202075 N 3 ST ST_NSOPRISTIQ TAB 58180020207520 581800202075 N 3 ST ST_NSOPRISTIQ TAB 58180020207540 581800202075 N 3 ST ST_NSOPRIVIGEN INJ 19100020102090 191000201020 N M NM PAprobenecid tab 68100010000310 681000100003 Y 1probenecid/colchicine tab 68990002100310 689900021003 Y 1PROCAINAMIDE INJ 35100020102010 351000201020 N M PA_BvDPROCAINAMIDE INJ 35100020102020 351000201020 N M PA_BvDPROCALAMINE INJ 3% 80302010152010 803020101520 N M PA_BvDPROCARDIA CAP 34000020000105 340000200001 O 3PROCARDIA XL TAB 34000020007570 340000200075 O 3PROCARDIA XL TAB 34000020007575 340000200075 O 3PROCARDIA XL TAB 34000020007580 340000200075 O 3PROCENTRA SOLN 61100020102020 611000201020 O 3prochlorperazine inj 59200055202005 592000552020 Y M PA_BvDprochlorperazine supp 59200055005215 592000550052 Y 1prochlorperazine tab 59200055100305 592000551003 Y 1prochlorperazine tab 59200055100310 592000551003 Y 1PROCRIT INJ 54868252300 82401020002040 824010200020 M 3 PA_BvDPROCRIT INJ 54868252301 82401020002040 824010200020 M 3 PA_BvDPROCRIT INJ 54868567301 82401020002050 824010200020 M 3 PA_BvDPROCRIT INJ 54868580200 82401020002060 824010200020 N 3 PA_BvDPROCRIT INJ 59676030200 82401020002010 824010200020 M 3 PA_BvDPROCRIT INJ 59676030201 82401020002010 824010200020 M 3 PA_BvDPROCRIT INJ 59676030202 82401020002010 824010200020 M 3 PA_BvDPROCRIT INJ 59676030300 82401020002015 824010200020 M 3 PA_BvDPROCRIT INJ 59676030301 82401020002015 824010200020 M 3 PA_BvDPROCRIT INJ 59676030302 82401020002015 824010200020 M 3 PA_BvD



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITPROCRIT INJ 59676030400 82401020002020 824010200020 M 3 PA_BvDPROCRIT INJ 59676030401 82401020002020 824010200020 M 3 PA_BvDPROCRIT INJ 59676030402 82401020002020 824010200020 M 3 PA_BvDPROCRIT INJ 59676031000 82401020002040 824010200020 M 3 PA_BvDPROCRIT INJ 59676031001 82401020002040 824010200020 M 3 PA_BvDPROCRIT INJ 59676031002 82401020002040 824010200020 M 3 PA_BvDPROCRIT INJ 59676031200 82401020002040 824010200020 M 3 PA_BvDPROCRIT INJ 59676031204 82401020002040 824010200020 M 3 PA_BvDPROCRIT INJ 59676032000 82401020002050 824010200020 M 3 PA_BvDPROCRIT INJ 59676032004 82401020002050 824010200020 M 3 PA_BvDPROCRIT INJ 59676034001 82401020002060 824010200020 N 3 PA_BvDPROCTOCORT CREAM 89100010003705 891000100037 O 3proctocream-HC 2.5% 89100010003720 891000100037 Y 1procto-pak cream 89100010003705 891000100037 Y 1progesterone cap 26000040100120 260000401001 Y 2progesterone cap 26000040100130 260000401001 Y 2PROGESTERONE SUPP 553700600052 N 3* PAPROGLYCEM SUSP 27300020001810 273000200018 N 3PROGRAF CAP 99404080000105 994040800001 O 3 PA_BvDPROGRAF CAP 99404080000110 994040800001 O 3 PA_BvDPROGRAF CAP 99404080000120 994040800001 O 3 PA_BvDPROGRAF INJ 99404080002010 994040800020 N M PA_BvDPROLASTIN INJ 45100010102110 451000101021 N M NM PA_BvDPROLASTIN-C INJ 45100010102120 451000101021 N M NMPROLENSA OPHTH SOLN 86805005102007 868050051020 N 2PROLEUKIN INJ 21703020002120 217030200021 N 2 NM PA_BvDPROLIA INJ 30044530002020 300445300020 N M PA_BvDPROMACTA TAB 82405030100310 824050301003 N 4 ESP NM PAPROMACTA TAB 82405030100320 824050301003 N 4 ESP NM PAPROMACTA TAB 82405030100330 824050301003 N 4 ESP NM PAPROMACTA TAB 82405030100340 824050301003 N 4 ESP NM PApromethazine DM syrup 439957023012 Y 3*promethazine inj 41400020102005 414000201020 Y Mpromethazine inj 41400020102010 414000201020 Y Mpromethazine supp 41400020105205 414000201052 Y 2promethazine supp 41400020105210 414000201052 Y 2promethazine supp 41400020105215 414000201052 Y 2promethazine syrup 41400020101210 414000201012 Y 1promethazine tab 41400020100305 414000201003 Y 1promethazine tab 41400020100310 414000201003 Y 1promethazine tab 41400020100315 414000201003 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITpromethazine VC syrup 6.25-5mg/5ml 43993002701210 439930027012 Y 1PROMETHAZINE VC W/CODEINE SYRUP 439953031012 N 1*promethazine w/codeine syrup 439952023412 Y 1*PROMETHEGAN SUPP 41400020105215 414000201052 N 2PROMETRIUM CAP 26000040100120 260000401001 O 3PROMETRIUM CAP 26000040100130 260000401001 O 3propafenone ER cap 35300050006920 353000500069 Y 2propafenone ER cap 35300050006930 353000500069 Y 2propafenone ER cap 35300050006940 353000500069 Y 2propafenone tab 35300050000320 353000500003 Y 1propafenone tab 35300050000325 353000500003 Y 1propafenone tab 35300050000330 353000500003 Y 1PROPANTHELINE TAB 49102070100310 491020701003 N 2propranolol ER cap 33100040107025 331000401070 Y 1propranolol ER cap 33100040107030 331000401070 Y 1propranolol ER cap 33100040107035 331000401070 Y 1propranolol ER cap 33100040107040 331000401070 Y 1propranolol inj 33100040102005 331000401020 Y M PA_BvDPROPRANOLOL SOLN 33100040102050 331000401020 N 1PROPRANOLOL SOLN 33100040102060 331000401020 N 1propranolol tab 33100040100305 331000401003 Y 1propranolol tab 33100040100310 331000401003 Y 1propranolol tab 33100040100315 331000401003 Y 1propranolol tab 33100040100320 331000401003 Y 1propranolol tab 33100040100325 331000401003 Y 1propranolol/hydrochlorothiazide tab 36992002400310 369920024003 Y 1propranolol/hydrochlorothiazide tab 36992002400320 369920024003 Y 1propylthiouracil tab 28300020000310 283000200003 Y 1PROQUAD INJ 17109904202200 171099042022 N $0PROSCAR TAB 56851030000320 568510300003 O 3PROSOL INJ 80302010102070 803020101020 N M PA_BvDPROTOPIC OINTMENT 90784075004210 907840750042 O 3PROTOPIC OINTMENT 90784075004230 907840750042 O 3protriptyline tab 58200070100305 582000701003 Y 2protriptyline tab 58200070100310 582000701003 Y 2PROVENTIL/PROAIR HFA INHALER 44201010103410 442010101034 N NCPROVERA TAB 26000020200305 260000202003 O 3PROVERA TAB 26000020200310 260000202003 O 3PROVERA TAB 26000020200315 260000202003 O 3PROVIGIL TAB 61400024000310 614000240003 O 3 PA QLPROVIGIL TAB 61400024000320 614000240003 O 3 PA QL



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITPROZAC CAP 58160040000110 581600400001 O 3PROZAC CAP 58160040000120 581600400001 O 3PROZAC CAP 58160040000140 581600400001 O 3pseudoephedrine/codeine/guaifenesin syrup 439973033020 Y 3* OTCPULMICORT NEB SUSP 44400015001830 444000150018 O 3 PA_BvD QLPULMICORT NEB SUSP 44400015001840 444000150018 O 3 PA_BvD QLPULMICORT NEB SUSP 44400015001850 444000150018 O 3 PA_BvD QLPULMOZYME INHALATION SOLN 1MG/ML 45304020002010 453040200020 N 4 ESP NM PA_BvDPURIXAN SUSP 21300040001830 213000400018 N MPYLERA CAP 49992003150120 499920031501 N 3pyrazinamide tab 09000070000310 090000700003 Y 1PYRIDIUM TAB 563000101003 O 3*pyridostigm tab 76000050100305 760000501003 Y 1pyridostigmine tab CR 180mg 76000050100405 760000501004 Y 2PYRIL D TAB 439930029918 O 3* OTCQNASL CHILDRENS INHALER 42200010303408 422000103034 N 3 QL STQNASL INHALER 42200010303430 422000103034 N 3 QL STQUADRACEL INJ 18990004351820 189900043518 N $0QUALAQUIN CAP 13000060100119 130000601001 O MQUARTETTE TAB 25993002300350 259930023003 N Mquasense tab 25993002300320 259930023003 Y $0QUESTRAN LIGHT POWDER 4GM/DOSE 39100010102905 391000101029 O 3QUESTRAN LIGHT POWDER PACK 391000101030 O 3*QUESTRAN POWDER 39100010002905 391000100029 O 3QUESTRAN POWDER 39100010003005 391000100030 O 3quetiapine tab 59153070100310 591530701003 Y 1quetiapine tab 59153070100314 591530701003 Y 1quetiapine tab 59153070100320 591530701003 Y 1quetiapine tab 59153070100330 591530701003 Y 1quetiapine tab 59153070100340 591530701003 Y 1quetiapine tab 59153070100350 591530701003 Y 1QUFLORA PEDIATRIC CHEW TAB 784410000005 N 3*QUFLORA PEDIATRIC DROP 784410000020 N 3*quinapril tab 36100040100305 361000401003 Y 1quinapril tab 36100040100310 361000401003 Y 1quinapril tab 36100040100320 361000401003 Y 1quinapril tab 36100040100340 361000401003 Y 1quinapril/hydrochlorothiazide tab 36991802650320 369918026503 Y 1quinapril/hydrochlorothiazide tab 36991802650330 369918026503 Y 1quinapril/hydrochlorothiazide tab 36991802650335 369918026503 Y 1quinidine gluconate CR tab 35100030100403 351000301004 Y 2



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITQUINIDINE GLUCONATE INJ 35100030102005 351000301020 N M PA_BvDQUINIDINE SULFATE ER TAB 35100030300405 351000303004 N 3QUINIDINE SULFATE TAB 35100030300310 351000303003 N 1QUINIDINE SULFATE TAB 35100030300315 351000303003 N 1QUINIDINE SULFATE TAB 35100030300315 351000303003 Y 1quinine sulfate cap 13000060100119 130000601001 Y MRABAVERT INJ 17100070201900 171000702019 N $0 PA_BvDrabeprazole tab 49270076100620 492700761006 Y 1rajani tab 25990003200320 259900032003 Y $0raloxifene tab 30053060100320 300530601003 Y $0ramipril cap 36100050000110 361000500001 Y 1ramipril cap 36100050000120 361000500001 Y 1ramipril cap 36100050000130 361000500001 Y 1ramipril cap 36100050000140 361000500001 Y 1RANEXA TAB 32200040007420 322000400074 N 2RANEXA TAB 32200040007430 322000400074 N 2ranitidine cap 49200020100105 492000201001 Y 1ranitidine cap 49200020100110 492000201001 Y 1ranitidine inj 49200020102006 492000201020 Y M PA_BvDranitidine inj 49200020102007 492000201020 Y M PA_BvDranitidine syrup 49200020101210 492000201012 Y 1ranitidine tab 49200020100305 492000201003 Y 1ranitidine tab 49200020100310 492000201003 Y 1RAPAFLO CAP 56852060000120 568520600001 N 2RAPAFLO CAP 56852060000140 568520600001 N 2RAPAMUNE SOLN 99404070002020 994040700020 N 2 PA_BvDRAPAMUNE TAB 99404070000310 994040700003 O 3 PA_BvDRAPAMUNE TAB 99404070000320 994040700003 O 3 PA_BvDRAPAMUNE TAB 99404070000330 994040700003 O 3 PA_BvDRAVICTI LIQUID 30908030000920 309080300009 N M NM PARAZADYNE ER CAP 62051030107020 620510301070 O 3RAZADYNE ER CAP 62051030107030 620510301070 O 3RAZADYNE ER CAP 62051030107040 620510301070 O 3RAZADYNE TAB 62051030100320 620510301003 O 3RAZADYNE TAB 62051030100330 620510301003 O 3RAZADYNE TAB 62051030100340 620510301003 O 3REBETOL CAP 12353070000120 123530700001 O 4 NMREBETOL SOLN 12353070002020 123530700020 N 4 ESP NMREBIF INJ TITRATION PACK 6240306045E560 6240306045E5 N 4 NM QLREBIF PREFILLED INJ 22MCG/0.5ML, 44MCG/0.5ML 6240306045E520 6240306045E5 N 4 NM QLREBIF PREFILLED INJ 22MCG/0.5ML, 44MCG/0.5ML 6240306045E540 6240306045E5 N 4 NM QL



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITREBIF REBIDOSE INJ 22MCG/0.5ML, 44MCG/0.5ML 6240306045D520 6240306045D5 N 4 NM QLREBIF REBIDOSE INJ 22MCG/0.5ML, 44MCG/0.5ML 6240306045D540 6240306045D5 N 4 NM QLREBIF REBIDOSE INJ TITRATION PACK 6240306045D560 6240306045D5 N 4 NM QLRECLAST INJ 30042090002020 300420900020 O M PA_BvDRECOMBIVAX-HB INJ 17100010201815 171000102018 N $0 PA_BvDRECOMBIVAX-HB INJ 17100010201820 171000102018 N $0 PA_BvDRECOMBIVAX-HB INJ 17100010201840 171000102018 N $0 PA_BvDREGLAN TAB 52300020100303 523000201003 O 3REGLAN TAB 52300020100305 523000201003 O 3REGRANEX GEL 90945020004020 909450200040 N 2 NM QLRELENZA DISKHALER 12504080008020 125040800080 N 2 QLRELISTOR INJ 12 MG/0.6ML 52580050102020 525800501020 N 3 ESP PARELISTOR INJ 8 MG/0.4ML 52580050102015 525800501020 N 4 ESP PARELISTOR INJ KIT 52580050106420 525800501064 N 3 PARELPAX TAB 67406025100320 674060251003 N M QLRELPAX TAB 67406025100340 674060251003 N M QLREMERON SOLUTAB 58030050007215 580300500072 O 3REMERON SOLUTAB 58030050007230 580300500072 O 3REMERON SOLUTAB 58030050007245 580300500072 O 3REMERON TAB 58030050000315 580300500003 O 3REMERON TAB 58030050000330 580300500003 O 3REMERON TAB 58030050000345 580300500003 O 3REMICADE INJ 52505040002120 525050400021 N M NM PAREMODULIN INJ 40170080102010 401700801020 N M NM PA_BvDREMODULIN INJ 40170080102020 401700801020 N M NM PA_BvDREMODULIN INJ 40170080102030 401700801020 N M NM PA_BvDREMODULIN INJ 40170080102040 401700801020 N M NM PA_BvDRENAGEL TAB 52800070100320 528000701003 N 3RENAGEL TAB 52800070100340 528000701003 N 3renaphro cap 781330000001 Y 1*RENVELA PACKET 52800070053020 528000700530 N 2RENVELA PACKET 52800070053040 528000700530 N 2RENVELA/SEVELAMER CARBONATE TAB 52800070050340 528000700503 N 2repaglinide tab 27280060000310 272800600003 Y 1repaglinide tab 27280060000320 272800600003 Y 1repaglinide tab 27280060000330 272800600003 Y 1REPAGLINIDE/METFORMIN TAB 27995002700320 279950027003 N 2REPAGLINIDE/METFORMIN TAB 27995002700330 279950027003 N 2REPLIVA TAB 829950054063 N 3*REPREXAIN TAB 2.5-200MG, 5-200MG 65991702500310 659917025003 O 3 QLREPREXAIN TAB 2.5-200MG, 5-200MG 65991702500315 659917025003 O 3 QL



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITREQUIP TAB 73203070100310 732030701003 O 3REQUIP TAB 73203070100315 732030701003 O 3REQUIP TAB 73203070100320 732030701003 O 3REQUIP TAB 73203070100330 732030701003 O 3REQUIP TAB 73203070100337 732030701003 O 3REQUIP TAB 73203070100344 732030701003 O 3REQUIP TAB 73203070100350 732030701003 O 3REQUIP XL TAB 73203070107520 732030701075 O 3REQUIP XL TAB 73203070107530 732030701075 O 3REQUIP XL TAB 73203070107535 732030701075 O 3REQUIP XL TAB 73203070107540 732030701075 O 3REQUIP XL TAB 73203070107550 732030701075 O 3RESCON TAB 439930024874 N 3*RESCRIPTOR TAB 12109020200320 121090202003 N 3RESCRIPTOR TAB 12109020200330 121090202003 N 3RESERPINE TAB 0.1MG 36203040000305 362030400003 N 3 QLRESERPINE TAB 0.25MG 36203040000310 362030400003 N 3RESTASIS OPHTH EMULSION 86720020001620 867200200016 N 2RESTORIL CAP 60201030000103 602010300001 O 3RESTORIL CAP 60201030000105 602010300001 O 3RESTORIL CAP 60201030000108 602010300001 O 3RESTORIL CAP 60201030000110 602010300001 O 3RETIN-A CREAM 90050030003703 900500300037 O 3 PARETIN-A CREAM 90050030003705 900500300037 O 3 PARETIN-A CREAM 90050030003710 900500300037 O 3 PARETIN-A GEL 90050030004005 900500300040 O 3 PARETIN-A GEL 90050030004010 900500300040 O 3 PARETIN-A MICRO GEL 90050030204015 900500302040 O 2 PARETIN-A MICRO GEL 90050030204020 900500302040 N 2 PARETIN-A MICRO GEL 90050030204030 900500302040 O 2 PARETROVIR CAP 12108085000110 121080850001 O 4RETROVIR INJ 12108085002020 121080850020 N MRETROVIR SYRUP 12108085001210 121080850012 O 4REVATIO INJ 40143060102020 401430601020 O M NM PAREVATIO SUSP 401430601019 N NCREVATIO SUSP 40143060101920 401430601019 N NCREVATIO TAB 40143060100320 401430601003 O 3 NM PAREVIA TAB 93400030100305 934000301003 O 3REVLIMID CAP 99394050000110 993940500001 N 4 ESP NM PA_NSO QLREVLIMID CAP 99394050000120 993940500001 N 4 ESP NM PA_NSO QLREVLIMID CAP 99394050000130 993940500001 N 4 ESP NM PA_NSO QL



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITREVLIMID CAP 99394050000140 993940500001 N 4 ESP NM PA_NSO QLREVLIMID CAP 99394050000145 993940500001 N 4 ESP NM PA_NSO QLREVLIMID CAP 99394050000150 993940500001 N 4 ESP NM PA_NSO QLREXULTI TAB 59250020000310 592500200003 N M PA_NSO QLREXULTI TAB 59250020000320 592500200003 N M PA_NSO QLREXULTI TAB 59250020000330 592500200003 N M PA_NSO QLREXULTI TAB 59250020000340 592500200003 N M PA_NSO QLREXULTI TAB 59250020000350 592500200003 N M PA_NSO QLREXULTI TAB 59250020000360 592500200003 N M PA_NSO QLREYATAZ CAP 12104515200130 121045152001 N 4 ESP NMREYATAZ CAP 12104515200140 121045152001 N 4 ESP NMREYATAZ CAP 12104515200150 121045152001 N 4 ESP NMREYATAZ POWDER PACKET 12104515203020 121045152030 N 4 ESP NMREZIRA SOLN 439951022420 N 3*RHEUMATREX TAB 66250050100320 662500501003 N 3RHINOCORT AQUA NASAL SPRAY 42200015001810 422000150018 O 3 QL STRIBAPAK TAB 400MG 12353070000340 123530700003 N MRIBAPAK TAB 600MG 12353070000360 123530700003 N M NMRIBAPAK TAB DOSE PACK 12353070006320 123530700063 M M NMribasphere tab 200mg 12353070000320 123530700003 Y 2ribavirin cap 200mg 12353070000120 123530700001 Y 2ribavirin tab 400mg 12353070000340 123530700003 Y 2RIBAVIRIN TAB 400MG, 600MG 12353070000340 123530700003 M 4 ESP NMRIBAVIRIN TAB 400MG, 600MG 12353070000360 123530700003 M 4 ESP NMribavirin tab 600mg 12353070000360 123530700003 Y 4 ESP NMRIDAURA CAP 66200010000105 662000100001 N 2rifabutin cap 09000075000120 090000750001 Y 2RIFADIN CAP 09000080000105 090000800001 O 3RIFADIN CAP 09000080000110 090000800001 O 3RIFADIN INJ 09000080002120 090000800021 O M PA_BvDRIFAMATE CAP 09990002100110 099900021001 N 2rifampin cap 09000080000105 090000800001 Y 2rifampin cap 09000080000110 090000800001 Y 2rifampin inj 09000080002120 090000800021 Y M PA_BvDRIFATER TAB 09990003200310 099900032003 N MRILUTEK TAB 74503070000320 745030700003 O M NMriluzole tab 74503070000320 745030700003 Y 2rimantadine tab 12500070100320 125000701003 Y 1ringers inj 79992001302010 799920013020 Y M PA_BvDringers irrigation soln 99750020002000 997500200020 Y M PA_BvDRIOMET SOLN 27250050002020 272500500020 N 3



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITrisedronate DR tab 30042065100635 300420651006 Y 2 STrisedronate tab 30042065100305 300420651003 Y 1 STrisedronate tab 30042065100320 300420651003 Y 1 STrisedronate tab 30042065100330 300420651003 Y 1 STrisedronate tab 30042065100380 300420651003 Y 1 STRISPERDAL INJ 59070070101910 590700701019 N M PA_BvDRISPERDAL INJ 59070070101920 590700701019 N M PA_BvDRISPERDAL INJ 59070070101930 590700701019 N M PA_BvDRISPERDAL INJ 59070070101940 590700701019 N M PA_BvDRISPERDAL M TAB 59070070007220 590700700072 O 3RISPERDAL M TAB 59070070007230 590700700072 O 3RISPERDAL M TAB 59070070007240 590700700072 O 3RISPERDAL M TAB 59070070007250 590700700072 O 3RISPERDAL M TAB 59070070007260 590700700072 O 3RISPERDAL SOLN 59070070002010 590700700020 O 3RISPERDAL TAB 59070070000303 590700700003 O 3RISPERDAL TAB 59070070000306 590700700003 O 3RISPERDAL TAB 59070070000310 590700700003 O 3RISPERDAL TAB 59070070000320 590700700003 O 3RISPERDAL TAB 59070070000330 590700700003 O 3RISPERDAL TAB 59070070000340 590700700003 O 3risperidone ODT 59070070007210 590700700072 Y 2risperidone ODT 59070070007220 590700700072 Y 2risperidone ODT 59070070007230 590700700072 Y 2risperidone ODT 59070070007240 590700700072 Y 2risperidone ODT 59070070007250 590700700072 Y 2risperidone ODT 59070070007260 590700700072 Y 2risperidone soln 59070070002010 590700700020 Y 1risperidone tab 59070070000303 590700700003 Y 1risperidone tab 59070070000306 590700700003 Y 1risperidone tab 59070070000310 590700700003 Y 1risperidone tab 59070070000320 590700700003 Y 1risperidone tab 59070070000330 590700700003 Y 1risperidone tab 59070070000340 590700700003 Y 1RITALIN LA CAP 61400020107010 614000201070 N 3RITALIN LA CAP 61400020107020 614000201070 O 3RITALIN LA CAP 61400020107030 614000201070 O 3RITALIN LA CAP 61400020107040 614000201070 O 3RITALIN LA CAP 61400020107048 614000201070 N 3RITALIN TAB 61400020100305 614000201003 O 3RITALIN TAB 61400020100310 614000201003 O 3



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITRITALIN TAB 61400020100315 614000201003 O 3RITUXAN INJ 21353060002020 213530600020 N M NM PA_BvDRITUXAN INJ 21353060002040 213530600020 N M NM PA_BvDrivastigmine cap 62051040200110 620510402001 Y 1rivastigmine cap 62051040200120 620510402001 Y 1rivastigmine cap 62051040200130 620510402001 Y 1rivastigmine cap 62051040200140 620510402001 Y 1rivastigmine patch 62051040008520 620510400085 Y 2rivastigmine patch 62051040008530 620510400085 Y 2rivastigmine patch 62051040008540 620510400085 Y 2rizatriptan ODT 67406060107220 674060601072 Y 1 QLrizatriptan ODT 67406060107230 674060601072 Y 1 QLrizatriptan tab 67406060100310 674060601003 Y 1 QLrizatriptan tab 67406060100320 674060601003 Y 1 QLROBAXIN TAB 75100070000305 751000700003 O 3ROBINUL FORTE TAB 49102030000315 491020300003 O 3ROBINUL INJ 49102030002012 491020300020 O M PA_BvDROBINUL INJ 49102030002013 491020300020 O M PA_BvDROBINUL INJ 49102030002014 491020300020 O M PA_BvDROBINUL INJ 65100055102057 651000551020 N M PA_BvDROBINUL TAB 49102030000310 491020300003 O 3ROCALTROL CAP 30905030000105 309050300001 O 3 PA_BvDROCALTROL CAP 30905030000110 309050300001 O 3 PA_BvDROCALTROL SOLN 30905030002050 309050300020 O 3 PA_BvDROCEPHIN INJ 02300090102110 023000901021 O MROCEPHIN INJ 02300090102115 023000901021 O Mropinirole ER tab 73203070107520 732030701075 Y 2ropinirole ER tab 73203070107530 732030701075 Y 2ropinirole ER tab 73203070107535 732030701075 Y 2ropinirole ER tab 73203070107540 732030701075 Y 2ropinirole ER tab 73203070107550 732030701075 Y 2ropinirole tab 73203070100310 732030701003 Y 1ropinirole tab 73203070100315 732030701003 Y 1ropinirole tab 73203070100320 732030701003 Y 1ropinirole tab 73203070100330 732030701003 Y 1ropinirole tab 73203070100337 732030701003 Y 1ropinirole tab 73203070100344 732030701003 Y 1ropinirole tab 73203070100350 732030701003 Y 1ROSULA FOAM 900599032039 N 3*rosuvastatin tab 39400060100305 394000601003 Y 2 QL RXCrosuvastatin tab 39400060100310 394000601003 Y 2 QL RXC



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITrosuvastatin tab 39400060100340 394000601003 Y 2 QL RXCrosuvastatin tab 20mg 39400060100320 394000601003 Y 2 QL RXCROTARIX SUSP 17100075001920 171000750019 N $0ROTATEQ SOLN 17100075102020 171000751020 N $0ROWASA KIT 52500030206420 525000302064 O MROXICET SOLN 325MG/5ML 65990002202005 659900022020 O 2 QLROXICODONE TAB 15MG, 30MG 65100075100325 651000751003 O 3 QLROXICODONE TAB 15MG, 30MG 65100075100340 651000751003 O 3 QLROXICODONE TAB 5MG 65100075100310 651000751003 O 3 QLROZEREM TAB 60250060000320 602500600003 N 3 PA QLRUCONEST INJ 85802022102130 858020221021 N M NM PARYTARY ER CAP 73209902100220 732099021002 N 3 STRYTARY ER CAP 73209902100230 732099021002 N 3 STRYTARY ER CAP 73209902100240 732099021002 N 3 STRYTARY ER CAP 73209902100250 732099021002 N 3 STRYTHMOL SR CAP 35300050006920 353000500069 O 3RYTHMOL SR CAP 35300050006930 353000500069 O 3RYTHMOL SR CAP 35300050006940 353000500069 O 3RYTHMOL TAB 35300050000320 353000500003 O 3RYTHMOL TAB 35300050000325 353000500003 O 3SABRIL POWDER 500MG 72170085003020 721700850030 N 2 NMSABRIL TAB 500MG 72170085000320 721700850003 N 2 NMSAFYRAL TAB 25990003200330 259900032003 N MSALAGEN TAB 88501560100310 885015601003 O 3SALAGEN TAB 88501560100320 885015601003 O 3SALEX SHAMPOO 907500300045 O 3* OTCsalsalate tab 641000750003 Y 1*SANCUSO PATCH 50250035005920 502500350059 N 3 QLSANDIMMUNE CAP 99402020000110 994020200001 O 3 PA_BvDSANDIMMUNE CAP 99402020000140 994020200001 O 3 PA_BvDSANDIMMUNE INJ 99402020002005 994020200020 O M PA_BvDSANDIMMUNE ORAL SOLN 99402020002010 994020200020 N 2 PA_BvDSANDOSTATIN INJ 30170070102005 301700701020 O 4 ESP NM PA_BvDSANDOSTATIN INJ 30170070102010 301700701020 O 4 ESP NM PA_BvDSANDOSTATIN INJ 30170070102015 301700701020 O 4 ESP NM PA_BvDSANDOSTATIN INJ 30170070102020 301700701020 O 4 ESP NM PA_BvDSANDOSTATIN INJ 30170070102030 301700701020 O 4 ESP NM PA_BvDSANDOSTATIN KIT LAR INJ 30170070106410 301700701064 N M NM PA_BvDSANDOSTATIN KIT LAR INJ 30170070106420 301700701064 N M NM PA_BvDSANDOSTATIN KIT LAR INJ 30170070106430 301700701064 N M NM PA_BvDSANTYL OINTMENT 90700010004205 907000100042 N 2



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITSAPHRIS SL TAB 59155015100710 591550151007 N 3 PA_NSO QLSAPHRIS SL TAB 59155015100720 591550151007 N 3 PA_NSO QLSAPHRIS SL TAB 59155015100730 591550151007 N 3 PA_NSO QLSAVELLA TAB 62504050100320 625040501003 N 2 QLSAVELLA TAB 62504050100330 625040501003 N 2 QLSAVELLA TAB 62504050100340 625040501003 N 2 QLSAVELLA TAB 62504050100350 625040501003 N 2 QLSAVELLA TAB TITRATION PACK 62504050106320 625040501063 N 2SEASONIQUE TAB 25993002300330 259930023003 O 3seb-prev cream 903000600037 Y 3*SECONAL CAP 60100070100110 601000701001 N 2SECTRAL CAP 33200010100105 332000101001 O 3SECTRAL CAP 33200010100110 332000101001 O 3selegiline cap 73300030100120 733000301001 Y 1selegiline tab 73300030100320 733000301003 Y 1selenium sulfide lotion 90300050004120 903000500041 Y 1selenium sulfide shampoo 90309903854520 903099038545 Y 2SELZENTRY TAB 12102060000320 121020600003 N 4 ESP NMSELZENTRY TAB 12102060000330 121020600003 N 4 ESP NMSEMPREX-D CAP 439930020301 N 3*SENSIPAR TAB 30905225100320 309052251003 N 2SENSIPAR TAB 30905225100330 309052251003 N 2SENSIPAR TAB 30905225100340 309052251003 N 2SEREVENT DISK 44201058108020 442010581080 N 2SEROQUEL TAB 59153070100310 591530701003 O 3SEROQUEL TAB 59153070100314 591530701003 O 3SEROQUEL TAB 59153070100320 591530701003 O 3SEROQUEL TAB 59153070100330 591530701003 O 3SEROQUEL TAB 59153070100340 591530701003 O 3SEROQUEL TAB 59153070100350 591530701003 O 3SEROQUEL XR TAB 59153070107505 591530701075 N 2SEROQUEL XR TAB 59153070107515 591530701075 N 2SEROQUEL XR TAB 59153070107520 591530701075 N 2SEROQUEL XR TAB 59153070107530 591530701075 N 2SEROQUEL XR TAB 59153070107540 591530701075 N 2SEROSTIM/SAIZEN/ZORBTIVE INJ 30100020102118 301000201021 N NCSEROSTIM/SAIZEN/ZORBTIVE INJ 30100020102120 301000201021 N NCSEROSTIM/SAIZEN/ZORBTIVE INJ 30100020102121 301000201021 N NCSEROSTIM/SAIZEN/ZORBTIVE INJ 30100020102125 301000201021 N NCSEROSTIM/SAIZEN/ZORBTIVE INJ 30100020102130 301000201021 N NCSEROSTIM/SAIZEN/ZORBTIVE INJ 30100020102132 301000201021 N NC



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITsertraline soln 58160070101320 581600701013 Y 1sertraline tab 58160070100305 581600701003 Y 1sertraline tab 58160070100310 581600701003 Y 1sertraline tab 58160070100320 581600701003 Y 1SFROWASA ENEMA 52500030005110 525000300051 N 3SIGNIFOR INJ 30170075202020 301700752020 N 2 NM PA QLSIGNIFOR INJ 30170075202030 301700752020 N 2 NM PA QLSIGNIFOR INJ 30170075202040 301700752020 N 2 NM PA QLsildenafil inj 40143060102020 401430601020 Y M NM PAsildenafil tab 40143060100320 401430601003 Y 1 PASILVADENE CREAM 90450030003710 904500300037 O 3silver sulfadiazine cream 90450030003710 904500300037 Y 1SIMBRINZA OPHTH SUSP 86609902201820 866099022018 N 2SIMCOR TAB 39409902707520 394099027075 N 2SIMCOR TAB 39409902707523 394099027075 N 2SIMCOR TAB 39409902707525 394099027075 N 2SIMCOR TAB 39409902707530 394099027075 N 2SIMCOR TAB 39409902707533 394099027075 N 2SIMPONI ARIA INJ 66270040002015 662700400020 N M NM PASIMPONI INJ 6627004000D520 6627004000D5 N 4 NM PASIMPONI INJ 6627004000D540 6627004000D5 N 4 NM PASIMPONI INJ 6627004000E520 6627004000E5 N 4 NM PASIMPONI INJ 6627004000E540 6627004000E5 N 4 NM PASIMULECT INJ 99405015002120 994050150021 N M NM PA_BvDsimvastatin tab 39400075000310 394000750003 Y 1simvastatin tab 39400075000320 394000750003 Y 1simvastatin tab 39400075000330 394000750003 Y 1simvastatin tab 39400075000340 394000750003 Y 1simvastatin tab 39400075000360 394000750003 Y 1SINEMET CR TAB 73209902100410 732099021004 O 3SINEMET CR TAB 73209902100420 732099021004 O 3SINEMET TAB 73209902100310 732099021003 O 3SINEMET TAB 73209902100320 732099021003 O 3SINEMET TAB 73209902100330 732099021003 O 3SINGULAIR CHEW TAB 44505050100516 445050501005 O 3SINGULAIR CHEW TAB 44505050100520 445050501005 O 3SINGULAIR GRANULES 44505050103020 445050501030 O 3SINGULAIR TAB 44505050100330 445050501003 O 3SINUVENT TAB 439962021003 N 3* OTCsirolimus tab 99404070000310 994040700003 Y 2 PA_BvDsirolimus tab 99404070000320 994040700003 Y 2 PA_BvD



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITsirolimus tab 99404070000330 994040700003 Y 2 PA_BvDSIRTURO TAB 09000015100320 090000151003 N M NMSIVEXTRO INJ 16230070202120 162300702021 N M NM PA QLSIVEXTRO TAB 16230070200320 162300702003 N 2 NM PA QLSKELAXIN TAB 75100060000320 751000600003 O 3SKLICE LOTION 90900017004120 909000170041 N 3 QLSLO-NIACIN TAB 771030100004 O 3* OTCSM B-COMPLEX/VITAMIN C TAB 781330000003 N 1*sodium bicarbonate inj 79050020002020 790500200020 Y M PA_BvDsodium bicarbonate inj 79050020002025 790500200020 Y M PA_BvDsodium chloride inj 79750010002010 797500100020 Y M PA_BvDsodium chloride inj 79750010002021 797500100020 Y M PA_BvDsodium chloride inj 79750010002030 797500100020 Y M PA_BvDsodium chloride inj 79750010002040 797500100020 Y M PA_BvDsodium chloride inj 79750010002045 797500100020 Y M PA_BvDsodium chloride inj 79750010002050 797500100020 Y M PA_BvDsodium chloride irrigation soln 56700060002010 567000600020 Y M PA_BvDsodium chloride neb 434000100025 Y 1*sodium citrate/citric acid soln 562020200020 Y 1*sodium fluoride chew tab 793000200005 Y $0*sodium fluoride cream 884020200037 Y $0*sodium fluoride gel 884020200040 Y 1*sodium fluoride paste 884020200044 Y 1*sodium fluoride rinse 884020200020 Y 1*sodium fluoride soln 793000200020 Y $0*SODIUM FLUORIDE TAB 793000200003 N $0*SODIUM FLUORIDE TAB 1MG 79300020000315 793000200003 N $0sodium fluoride/potassium nitrate paste 884099027744 Y 1*sodium lactate inj 79050030002010 790500300020 Y M PA_BvDsodium phenylbutyrate oral powder 30908060002950 309080600029 Y 2sodium polystyrene oral susp 99450010001840 994500100018 Y 1sodium polystyrene powder 99450010002900 994500100029 Y 2sodium polystyrene susp 994500100018 Y 1*sodium sulfacetamide gel 903000600040 Y 3*sodium sulfacetamide ophth soln 86102010102010 861020101020 Y 1sodium sulfacetamide shampoo 903000600045 Y 3*sodium sulfacetamide/urea pad 903099026043 Y 3*SOLARAZE GEL 90374035304020 903740353040 O 3SOLTAMOX ORAL SOLN 21402680102020 214026801020 N M PA_NSOSOLU-CORTEF INJ 22100025402150 221000254021 N M PA_BvDSOLU-CORTEF INJ 22100025402155 221000254021 N M PA_BvD



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITSOLU-CORTEF INJ 22100025402161 221000254021 N M PA_BvDSOLU-CORTEF INJ 22100025402165 221000254021 N M PA_BvDSOLU-MEDROL INJ 22100030202105 221000302021 O M PA_BvDSOLU-MEDROL INJ 22100030202110 221000302021 O M PA_BvDSOLU-MEDROL INJ 22100030202115 221000302021 N M PA_BvDSOLU-MEDROL INJ 22100030202130 221000302021 N M PA_BvDSOMA TAB 75100020000305 751000200003 O 3SOMATULINE INJ 30170050102025 301700501020 N M NM PA_BvDSOMATULINE INJ 30170050102030 301700501020 N M NM PA_BvDSOMATULINE INJ 30170050102040 301700501020 N M NM PA_BvDSOMAVERT INJ 30180060002120 301800600021 N 2 NM PA_BvDSOMAVERT INJ 30180060002130 301800600021 N 2 NM PA_BvDSOMAVERT INJ 30180060002140 301800600021 N 2 NM PA_BvDSOMAVERT INJ 30180060002150 301800600021 N 2 NM PA_BvDSOMAVERT INJ 30180060002160 301800600021 N 2 NM PA_BvDSONATA CAP 60204070000120 602040700001 O 3 QLSONATA CAP 60204070000130 602040700001 O 3 QLSORBITOL SOLN 466000700020 N 1*SORIATANE CAP 90250510000110 902505100001 O 3SORIATANE CAP 90250510000115 902505100001 O 3SORIATANE CAP 90250510000125 902505100001 O 3SORILUX FOAM 90250025003920 902500250039 N 3sotalol AF tab 33100045120310 331000451203 Y 1sotalol AF tab 33100045120315 331000451203 Y 1sotalol AF tab 33100045120320 331000451203 Y 1SOTALOL INJ 33100045102030 331000451020 N M PA_BvDsotalol tab 33100045100310 331000451003 Y 1sotalol tab 33100045100315 331000451003 Y 1sotalol tab 33100045100320 331000451003 Y 1sotalol tab 33100045100330 331000451003 Y 1SOVALDI TAB 12353080000320 123530800003 N 4 ESP NM PA QLSPECTRACEF TAB 02300045200320 023000452003 M 3SPECTRACEF TAB 02300045200340 023000452003 M 3SPINOSAD SUSP/NATROBA SUSP 90900048001820 909000480018 M 2SPIRIVA HANDIHALER 44100080100120 441000801001 N 2SPIRIVA RESPIMAT INHALER 44100080103410 441000801034 N 2SPIRIVA RESPIMAT INHALER 44100080103420 441000801034 N 2spironolactone tab 37500020000305 375000200003 Y 1spironolactone tab 37500020000310 375000200003 Y 1spironolactone tab 37500020000315 375000200003 Y 1spironolactone/hydrochlorothiazide tab 37990002200310 379900022003 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITSPORANOX CAP 11407035000120 114070350001 O 3 PASPORANOX SOLN 11407035002020 114070350020 N 3 PASPRITAM ODT 7260004300G820 7260004300G8 N M PA_NSOSPRITAM ODT 7260004300G830 7260004300G8 N M PA_NSOSPRITAM ODT 7260004300G840 7260004300G8 N M PA_NSOSPRITAM ODT 7260004300G850 7260004300G8 N M PA_NSOSPRYCEL TAB 21534020000320 215340200003 N 2 PA_NSOSPRYCEL TAB 21534020000340 215340200003 N 2 PA_NSOSPRYCEL TAB 21534020000350 215340200003 N 2 PA_NSOSPRYCEL TAB 21534020000354 215340200003 N 2 PA_NSOSPRYCEL TAB 21534020000360 215340200003 N 2 PA_NSOSPRYCEL TAB 21534020000380 215340200003 N 2 PA_NSOSTARLIX TAB 27280040000320 272800400003 O 3STARLIX TAB 27280040000330 272800400003 O 3stavudine cap 12108070000115 121080700001 Y 2stavudine cap 12108070000120 121080700001 Y 2stavudine cap 12108070000130 121080700001 Y 2stavudine cap 12108070000140 121080700001 Y 2stavudine soln 12108070002120 121080700021 Y 2STELARA INJ 45MG/0.5ML 9025058500E520 9025058500E5 N 4 NM PA QLSTELARA INJ 90MG/ML 9025058500E540 9025058500E5 N 4 NM PAsterile water irrigation 99750005002000 997500050020 Y M PA_BvDSTIMATE NASAL SPRAY 30201010102015 302010101020 N 2STIOLTO INHALER 44209902923420 442099029234 N 2STIVARGA TAB 21533050000320 215330500003 N 4 ESP NM PA_NSO QLSTRATTERA CAP 61354015100110 613540151001 N 3 QLSTRATTERA CAP 61354015100118 613540151001 N 3 QLSTRATTERA CAP 61354015100125 613540151001 N 3 QLSTRATTERA CAP 61354015100140 613540151001 N 3 QLSTRATTERA CAP 61354015100160 613540151001 N 3 QLSTRATTERA CAP 61354015100170 613540151001 N 3 QLSTRATTERA CAP 61354015100180 613540151001 N 3 QLSTRENSIQ INJ 40MG/ML 30905610002040 309056100020 N 4 ESP NM PASTRENSIQ INJ 80MG/0.8ML 30905610002050 309056100020 N 4 ESP NM PASTREPTOMYCIN INJ 07000060102105 070000601021 N M PA_BvDSTRIBILD TAB 12109904300320 121099043003 N 4 ESP NMSTROMECTOL TAB 15000007000310 150000070003 O 3STROVITE TAB 783100000003 O 3* OTCSUBLIMAZE INJ. 65100025102012 651000251020 O NCSUBLIMAZE INJ. 65100025102022 651000251020 O NCSUBLIMAZE INJ. 65100025102037 651000251020 O NC



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITSUBOXONE FILM 12-3MG 65200010208250 652000102082 N 2 QLSUBOXONE FILM 2-0.5MG, 4-1MG, 8-2MG 65200010208220 652000102082 N 2 QLSUBOXONE FILM 2-0.5MG, 4-1MG, 8-2MG 65200010208230 652000102082 N 2 QLSUBOXONE FILM 2-0.5MG, 4-1MG, 8-2MG 65200010208240 652000102082 N 2 QLSUBSYS SPRAY 65100025000910 651000250009 N NCSUBSYS SPRAY 65100025000920 651000250009 N NCSUBSYS SPRAY 65100025000930 651000250009 N NCSUBSYS SPRAY 65100025000940 651000250009 N NCSUBSYS SPRAY 65100025000950 651000250009 N NCSUBSYS SPRAY 65100025000960 651000250009 N NCSUBSYS SPRAY 65100025000970 651000250009 N NCsucralfate tab 49300010000305 493000100003 Y 1SULAR TAB 34000024007508 340000240075 O 3SULAR TAB 34000024007517 340000240075 O 3SULAR TAB 34000024007535 340000240075 O 3sulfacetamide lotion 90051036104120 900510361041 Y 2SULFACETAMIDE SODIUM OPHTH OINTMENT 86102010104205 861020101042 N Msulfacetamide sodium/sulfur aerosol 900599032039 Y 3*sulfacetamide sodium/sulfur emulsion 900599032016 Y 2*sulfacetamide sodium/sulfur lotion 900599032041 Y 1*SULFACETAMIDE/SULFUR EMULSION 90059903211618 900599032116 N 2SULFACETAMIDE/SULFUR EMULSION 90059903211620 900599032116 N 2sulfacleanse susp 900599032018 Y 3*SULFADIAZINE TAB 08000020000305 080000200003 N 1sulfamethoxazole/trimethoprim 400mg-80mg tab 16990002300310 169900023003 Y 1sulfamethoxazole/trimethoprim DS tab 16990002300320 169900023003 Y 1SULFAMETHOXAZOLE/TRIMETHOPRIM INJ 16990002302010 169900023020 N M PA_BvDsulfamethoxazole/trimethoprim susp 16990002301810 169900023018 Y 1SULFAMYLON CREAM 90450010103710 904500101037 N 2SULFAMYLON SOLN 90450010103020 904500101030 O Msulfasalazine tab 52500060000310 525000600003 Y 1sulfazine DR tab 52500060000610 525000600006 Y 1sulfcetamide/prednisolone ophth soln 86309902722015 863099027220 Y 1sulindac tab 66100080000305 661000800003 Y 1sulindac tab 66100080000310 661000800003 Y 1SUMADAN WASH 90059903200914 900599032009 O 3SUMADAN WASH 90059903200915 900599032009 O 3sumatriptan auto-injector 4mg/0.5ml, 6mg/0.5ml 6740607010D510 6740607010D5 Y 1 QLsumatriptan auto-injector 4mg/0.5ml, 6mg/0.5ml 6740607010D520 6740607010D5 Y 1 QLsumatriptan inj 4mg/0.5ml, 6mg/0.5ml 67406070102005 674060701020 Y 1 QLsumatriptan inj 4mg/0.5ml, 6mg/0.5ml 67406070102010 674060701020 Y 1 QL



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITSUMATRIPTAN INJ 6MG/0.5ML 6740607010E520 6740607010E5 N 1 QLsumatriptan nasal spray 67406070002010 674060700020 Y 2 QLsumatriptan nasal spray 67406070002040 674060700020 Y 2 QLsumatriptan refill inj 4mg/0.5ml, 6mg/0.5ml 6740607010E210 6740607010E2 Y 1 QLsumatriptan refill inj 4mg/0.5ml, 6mg/0.5ml 6740607010E220 6740607010E2 Y 1 QLsumatriptan tab 67406070100305 674060701003 Y 1 QLsumatriptan tab 67406070100310 674060701003 Y 1 QLsumatriptan tab 67406070100320 674060701003 Y 1 QLSUMATRIPTAN/IMITREX NASAL SPRAY 67406070002010 674060700020 O 2 QLSUMATRIPTAN/IMITREX NASAL SPRAY 67406070002040 674060700020 O 2 QLSUMAVEL DOSEPRO INJ 6740607010D810 6740607010D8 N 3 QLSUMAVEL DOSEPRO INJ 6740607010D820 6740607010D8 N 3 QLSUMAXIN PAD 900599032043 O 3*SUMAXIN SUSP 900599032018 O 3*SUPRAX CAP 02300060000120 023000600001 N 3SUPRAX CHEW TAB 02300060000510 023000600005 N 3SUPRAX CHEW TAB 02300060000530 023000600005 N 3SUPRAX SUSP 02300060001910 023000600019 O 3SUPRAX SUSP 02300060001920 023000600019 O 3SUPRAX SUSP 02300060001930 023000600019 N 3SURMONTIL CAP 58200080100105 582000801001 O 3SURMONTIL CAP 58200080100110 582000801001 O 3SURMONTIL CAP 58200080100115 582000801001 O 3SUSTIVA CAP 12109030000110 121090300001 N 2SUSTIVA CAP 12109030000140 121090300001 N 2SUSTIVA TAB 12109030000330 121090300003 N 2SUTENT CAP 21533070300120 215330703001 N 4 ESP NM PA_NSOSUTENT CAP 21533070300130 215330703001 N 4 ESP NM PA_NSOSUTENT CAP 21533070300135 215330703001 N 4 ESP NM PA_NSOSUTENT CAP 21533070300140 215330703001 N 4 ESP NM PA_NSOSUTTAR-SF SYRUP 439973033012 O 3*SYLATRON KIT 21700075206410 217000752064 N 4 NM PA_NSOSYLATRON KIT 21700075206420 217000752064 N 4 NM PA_NSOSYLATRON KIT 21700075206430 217000752064 N 4 NM PA_NSOSYLATRON KIT 21700075206450 217000752064 N 4 NM PA_NSOSYLATRON KIT 21700075206460 217000752064 N 4 NM PA_NSOSYLVANT INJ 99473080002120 994730800021 N M NM PA_BvDSYMAX DUOTAB 491010301004 N 3*SYMBYAX CAP 62995002500110 629950025001 O 3SYMBYAX CAP 62995002500120 629950025001 O 3SYMBYAX CAP 62995002500125 629950025001 O 3



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITSYMBYAX CAP 62995002500140 629950025001 O 3SYMBYAX CAP 62995002500145 629950025001 O 3SYMLINPEN INJ 2715005010D220 2715005010D2 N MSYMLINPEN INJ 2715005010D240 2715005010D2 N MSYNAGIS INJ 19502060002015 195020600020 N M NM PASYNAGIS INJ 19502060002020 195020600020 N M NM PASYNAREL NASAL SOLN 30080055102020 300800551020 N 2 NMSYNERCID INJ 16259902502120 162599025021 N M NM PA_BvDSYNJARDY TAB 27996002400310 279960024003 N 2 QLSYNJARDY TAB 27996002400315 279960024003 N 2 QLSYNJARDY TAB 27996002400320 279960024003 N 2 QLSYNJARDY TAB 27996002400325 279960024003 N 2 QLSYNRIBO INJ 21700040102120 217000401021 N M NM PA_BvDSYNTHROID TAB 28100010100305 281000101003 O 3SYNTHROID TAB 28100010100310 281000101003 O 3SYNTHROID TAB 28100010100315 281000101003 O 3SYNTHROID TAB 28100010100317 281000101003 O 3SYNTHROID TAB 28100010100320 281000101003 O 3SYNTHROID TAB 28100010100322 281000101003 O 3SYNTHROID TAB 28100010100325 281000101003 O 3SYNTHROID TAB 28100010100327 281000101003 O 3SYNTHROID TAB 28100010100330 281000101003 O 3SYNTHROID TAB 28100010100335 281000101003 O 3SYNTHROID TAB 28100010100340 281000101003 O 3SYNTHROID TAB 28100010100345 281000101003 O 3SYPRINE CAP 99200020100110 992000201001 N 3TABLOID TAB 21300060000305 213000600003 N 2TACLONEX OINTMENT 90559902324225 905599023242 O 3TACLONEX SCALP 90559902321825 905599023218 N 3tacrolimus cap 99404080000105 994040800001 Y 2 PA_BvDtacrolimus cap 99404080000110 994040800001 Y 2 PA_BvDtacrolimus cap 99404080000120 994040800001 Y 2 PA_BvDtacrolimus ointment 90784075004210 907840750042 Y 2tacrolimus ointment 90784075004230 907840750042 Y 2TAFINLAR CAP 21532025100120 215320251001 N 2 NM PA_NSO QLTAFINLAR CAP 21532025100130 215320251001 N 2 NM PA_NSO QLTAGAMET TAB 492000100003 O 3*TAGRISSO TAB 21534065200320 215340652003 N M NM PA_NSOTAGRISSO TAB 21534065200330 215340652003 N M NM PA_NSOTAMIFLU CAP 30MG 12504060200110 125040602001 N 2 QLTAMIFLU CAP 45MG 12504060200115 125040602001 N 2 QL



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITTAMIFLU CAP 75MG 12504060200120 125040602001 N 2 QLTAMIFLU SUSP 6MG/ML 12504060201910 125040602019 N 2 QLtamoxifen tab 21402680100310 214026801003 Y $0tamoxifen tab 21402680100320 214026801003 Y $0tamsulosin cap 56852070100110 568520701001 Y 1TAPAZOLE TAB 28300010000305 283000100003 O 3TAPAZOLE TAB 28300010000310 283000100003 O 3TARCEVA TAB 21534025100320 215340251003 N 4 ESP NM PA_NSOTARCEVA TAB 21534025100330 215340251003 N 4 ESP NM PA_NSOTARCEVA TAB 21534025100360 215340251003 N 4 ESP NM PA_NSOTARGRETIN CAP 21708220000120 217082200001 O 4 NM PA_NSOTARGRETIN GEL 90376220004020 903762200040 N 4 ESP NMTARKA TAB 36991502700420 369915027004 O 3TARKA TAB 36991502700432 369915027004 O 3TARKA TAB 36991502700436 369915027004 O 3TARKA TAB 36991502700452 369915027004 O 3TASIGNA CAP 21534060200115 215340602001 N 4 NM PA_NSOTASIGNA CAP 21534060200125 215340602001 N 4 NM PA_NSOTASMAR TAB 73152070000320 731520700003 O 3TAXOL INJ 21500012001340 215000120013 N M PA_BvDTAXOTERE INJ 21500005001310 215000050013 O M NM PA_BvDTAXOTERE INJ 21500005001315 215000050013 O M NM PA_BvDTAXOTERE INJ 21500005001320 215000050013 N M NM PA_BvDTAXOTERE INJ 21500005001325 215000050013 N M NM PA_BvDTAZORAC CREAM 90250070003720 902500700037 N 3TAZORAC CREAM 90250070003730 902500700037 N 3TAZORAC GEL 90250070004020 902500700040 N 3TAZORAC GEL 90250070004030 902500700040 N 3TECENTRIQ INJ 21353015002020 213530150020 N M NM PA_NSOTECFIDERA CAP 62405525006520 624055250065 N 4 ESP NMTECFIDERA CAP 62405525006540 624055250065 N 4 ESP NMTECFIDERA CAP STARTER PACK 62405525006320 624055250063 N 4 ESP NMTEFLARO INJ 02500030102120 025000301021 N M NM PA_BvDTEFLARO INJ 02500030102130 025000301021 N M NM PA_BvDTEGRETOL SUSP 72600020001810 726000200018 O 3TEGRETOL TAB 72600020000305 726000200003 O 3TEGRETOL XR TAB 72600020007410 726000200074 O 3TEGRETOL XR TAB 72600020007420 726000200074 O 3TEGRETOL XR TAB 72600020007440 726000200074 O 3TEKTURNA HCT TAB 36996002150320 369960021503 N 3TEKTURNA HCT TAB 36996002150325 369960021503 N 3



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITTEKTURNA HCT TAB 36996002150340 369960021503 N 3TEKTURNA HCT TAB 36996002150345 369960021503 N 3TEKTURNA TAB 36170010100320 361700101003 N 3TEKTURNA TAB 36170010100340 361700101003 N 3telmisartan tab 36150070000310 361500700003 Y 2telmisartan tab 36150070000320 361500700003 Y 2telmisartan tab 36150070000340 361500700003 Y 2telmisartan/amlodipine tab 36993002700320 369930027003 Y 2telmisartan/amlodipine tab 36993002700330 369930027003 Y 2telmisartan/amlodipine tab 36993002700340 369930027003 Y 2telmisartan/amlodipine tab 36993002700350 369930027003 Y 2telmisartan/hydrochlorothiazide tab 36994002600320 369940026003 Y 2telmisartan/hydrochlorothiazide tab 36994002600340 369940026003 Y 2telmisartan/hydrochlorothiazide tab 36994002600345 369940026003 Y 2temazepam cap 15mg, 30mg 60201030000105 602010300001 Y 1temazepam cap 15mg, 30mg 60201030000110 602010300001 Y 1temazepam cap 7.5mg, 22.5mg 60201030000103 602010300001 Y 2temazepam cap 7.5mg, 22.5mg 60201030000108 602010300001 Y 2TEMODAR CAP 211040700001 O 4* ESPTEMOVATE CREAM 90550025103705 905500251037 O 3TEMOVATE E CREAM 905500251537 O 3*TEMOVATE GEL 90550025104010 905500251040 O 3TEMOVATE OINTMENT 90550025104205 905500251042 O 3TEMOVATE SOLN 90550025102005 905500251020 O 3temozolomide cap 211040700001 Y 4* ESPTENEX TAB 36201025100320 362010251003 O 3TENEX TAB 36201025100330 362010251003 O 3TENIVAC INJ 18990002202210 189900022022 N $0 PA_BvDTENORETIC TAB 36992002100310 369920021003 O 3TENORETIC TAB 36992002100320 369920021003 O 3TENORMIN TAB 33200020000303 332000200003 O 3TENORMIN TAB 33200020000305 332000200003 O 3TENORMIN TAB 33200020000310 332000200003 O 3TERAZOL 3 CREAM 55104070003720 551040700037 O 3TERAZOL 7 CREAM 55104070003710 551040700037 O 3terazosin cap 36202040100105 362020401001 Y 1terazosin cap 36202040100110 362020401001 Y 1terazosin cap 36202040100115 362020401001 Y 1terazosin cap 36202040100120 362020401001 Y 1terbinafine tab 11000080100310 110000801003 Y 1terbutaline sulfate inj 44201060202005 442010602020 Y M PA_BvD



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITterbutaline tab 44201060200305 442010602003 Y 1terbutaline tab 44201060200310 442010602003 Y 1terconazole cream 55104070003710 551040700037 Y 1terconazole cream 55104070003720 551040700037 Y 1terconazole supp 55104070005210 551040700052 Y 1TESSALON/ZONATUSS CAP 431020100001 O 3*TEST STRIP 941000300061 N NC OTCTEST STRIP 941000300098 N NC OTCtestosterone cypionate inj 23100030102010 231000301020 Y 1 PA_BvDtestosterone cypionate inj 23100030102015 231000301020 Y 1 PA_BvDtestosterone enanthate inj 23100030202010 231000302020 Y M PA_BvDTESTOSTERONE GEL 1% 45802011665 23100030004025 231000300040 N 3 PA QLtestosterone gel 1% (25mg) 23100030004025 231000300040 Y 2 PA QLtestosterone gel 1% (50mg) 23100030004030 231000300040 Y 2 PA QLTESTOSTERONE GEL/TESTIM GEL 23100030004030 231000300040 M 3 PA QLtestosterone pump 1% 23100030004040 231000300040 Y 2 PA QLTETANUS TOXOID INJ 18000020202005 180000202020 N $0TETANUS/DIPTHERIA TOXOID INJ 18990002201805 189900022018 N $0tetrabenazine tab 62380070000310 623800700003 Y 2 ESP NM PAtetrabenazine tab 62380070000320 623800700003 Y 2 ESP NM PATETRACYCLINE CAP 04000060100105 040000601001 O 3tetracycline cap 04000060100105 040000601001 Y 3TETRACYCLINE CAP 04000060100110 040000601001 O 3tetracycline cap 04000060100110 040000601001 Y 3TEVETEN HCT TAB 36994002250320 369940022503 N 3TEVETEN HCT TAB 36994002250325 369940022503 N 3TEVETEN TAB 36150024200330 361500242003 O 3TEXACORT SOLN 905500750020 N 3*THALOMID CAP 99392070000120 993920700001 N 4 ESP NM PA_NSOTHALOMID CAP 99392070000130 993920700001 N 4 ESP NM PA_NSOTHALOMID CAP 99392070000135 993920700001 N 4 ESP NM PA_NSOTHALOMID CAP 99392070000140 993920700001 N 4 ESP NM PA_NSOTHEO-24 CR CAP 44300040007020 443000400070 N 3THEO-24 CR CAP 44300040007030 443000400070 N 3THEO-24 CR CAP 44300040007040 443000400070 N 3THEO-24 CR CAP 44300040007050 443000400070 N 3theophylline ER tab 44300040007420 443000400074 Y 1theophylline ER tab 44300040007430 443000400074 Y 1theophylline ER tab 44300040007440 443000400074 Y 1theophylline ER tab 44300040007455 443000400074 Y 1theophylline ER tab 44300040007540 443000400075 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITtheophylline ER tab 44300040007560 443000400075 Y 1theophylline soln 44300040002010 443000400020 Y 1THIOLA TAB 56600050000310 566000500003 N Mthioridazine tab 59200080100305 592000801003 Y 1thioridazine tab 59200080100315 592000801003 Y 1thioridazine tab 59200080100320 592000801003 Y 1thioridazine tab 59200080100325 592000801003 Y 1THIOTEPA INJ 21100040002105 211000400021 N M PA_BvDthiothixene cap 59300020100105 593000201001 Y 1thiothixene cap 59300020100110 593000201001 Y 1thiothixene cap 59300020100115 593000201001 Y 1thiothixene cap 59300020100120 593000201001 Y 1THYMOGLOBULIN INJ 99402540302120 994025403021 N M NM PA_BvDthyroid tab 281000500003 Y 1*THYROLAR TAB 28100030000305 281000300003 N 2THYROLAR TAB 28100030000310 281000300003 N 2THYROLAR TAB 28100030000315 281000300003 N 2THYROLAR TAB 28100030000320 281000300003 N 2THYROLAR TAB 28100030000325 281000300003 N 2tiagabine tab 72170070100302 721700701003 Y 2tiagabine tab 72170070100305 721700701003 Y 2TIAZAC CAP 34000010117020 340000101170 O 3TIAZAC CAP 34000010117030 340000101170 O 3TIAZAC CAP 34000010117040 340000101170 O 3TIAZAC CAP 34000010117050 340000101170 O 3TIAZAC CAP 34000010117060 340000101170 O 3TIAZAC CAP 34000010117070 340000101170 O 3TICLOPIDINE TAB 85158080100320 851580801003 N 1ticlopidine tab 85158080100320 851580801003 Y 1TIGAN CAP 50200070100120 502000701001 O 3TIGAN INJ 50200070102005 502000701020 N MTIKOSYN CAP 35400025000110 354000250001 O 2TIKOSYN CAP 35400025000120 354000250001 O 2TIKOSYN CAP 35400025000130 354000250001 O 2timolol maleate ophth soln 86250030102005 862500301020 Y 1timolol maleate ophth soln 86250030102010 862500301020 Y 1timolol maleate tab 33100050100305 331000501003 Y 1timolol maleate tab 33100050100310 331000501003 Y 1timolol maleate tab 33100050100315 331000501003 Y 1timolol ophth gel 86250030107620 862500301076 Y 1timolol ophth gel 86250030107630 862500301076 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITTIMOPTIC OCUDOSE OPHTH SOLN 86250030102006 862500301020 N 3TIMOPTIC OCUDOSE OPHTH SOLN 86250030102011 862500301020 N 3TIMOPTIC OPHTH SOLN 86250030102005 862500301020 O 3TIMOPTIC OPHTH SOLN 86250030102010 862500301020 O 3TIMOPTIC-XE OPHTH SOLN 86250030107620 862500301076 O 3TIMOPTIC-XE OPHTH SOLN 86250030107630 862500301076 O 3TINDAMAX TAB 16000053000310 160000530003 O 3TINDAMAX TAB 16000053000320 160000530003 O 3tinidazole tab 16000053000310 160000530003 Y 2tinidazole tab 16000053000320 160000530003 Y 2TIROSINT CAP 28100010100105 281000101001 N 3TIROSINT CAP 28100010100110 281000101001 N 3TIROSINT CAP 28100010100115 281000101001 N 3TIROSINT CAP 28100010100120 281000101001 N 3TIROSINT CAP 28100010100125 281000101001 N 3TIROSINT CAP 28100010100130 281000101001 N 3TIROSINT CAP 28100010100135 281000101001 N 3TIROSINT CAP 28100010100140 281000101001 N 3TIROSINT CAP 28100010100145 281000101001 N 3TIROSINT CAP 28100010100150 281000101001 N 3TIVICAY 50MG TAB 12103015100320 121030151003 N 4 ESP NM QLTIVICAY TAB 12103015100305 121030151003 N 4 ESP QLTIVICAY TAB 12103015100310 121030151003 N 4 ESP QLtizanidine cap 75100090100110 751000901001 Y 2tizanidine cap 75100090100120 751000901001 Y 2tizanidine cap 75100090100130 751000901001 Y 2tizanidine tab 75100090100310 751000901003 Y 1tizanidine tab 75100090100320 751000901003 Y 1TOBI NEB 07000070002520 070000700025 O 4 NM PATOBI PODHALER 07000070000120 070000700001 N 4 ESP NM PATOBRADEX OPHTH OINTMENT 86309902804220 863099028042 N 2TOBRADEX OPHTH SUSP 86309902801820 863099028018 O 3TOBRADEX ST OPHTH SOLN 86309902801810 863099028018 N 3TOBRAMYCIN INJ 07000070102020 070000701020 N M PA_BvDtobramycin inj 07000070102020 070000701020 Y M PA_BvDtobramycin inj 07000070102034 070000701020 Y M PA_BvDtobramycin inj 07000070102038 070000701020 Y M PA_BvDTOBRAMYCIN INJ 07000070102039 070000701020 N M PA_BvDtobramycin inj 07000070102039 070000701020 Y M PA_BvDtobramycin neb 07000070002520 070000700025 Y 4 ESP NM PAtobramycin ophth soln 0.3% 86101070002005 861010700020 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITtobramycin/dexamethasone ophth susp 86309902801820 863099028018 Y 1TOBRAMYCIN/NACL INJ 07000070122020 070000701220 N M PA_BvDTOBREX OPHTH OINTMENT 86101070004205 861010700042 N 3TOBREX OPHTH SOLN 86101070002005 861010700020 O 3TOFRANIL TAB 58200050100305 582000501003 O 3TOFRANIL TAB 58200050100310 582000501003 O 3TOFRANIL TAB 58200050100315 582000501003 O 3TOFRANIL-PM CAP 58200050200105 582000502001 O 3TOFRANIL-PM CAP 58200050200110 582000502001 O 3TOFRANIL-PM CAP 58200050200115 582000502001 O 3TOFRANIL-PM CAP 58200050200120 582000502001 O 3TOLAK CREAM 903720300037 N 2*tolazamide tab 27200050000310 272000500003 Y 1tolazamide tab 27200050000315 272000500003 Y 1TOLBUTAMIDE TAB 27200060000310 272000600003 N 2tolcapone tab 73152070000320 731520700003 Y 2TOLMETIN CAP 66100090100105 661000901001 N 1tolmetin sodium cap 66100090100105 661000901001 Y 1TOLMETIN SODIUM TAB 66100090100305 661000901003 N 1TOLMETIN SODIUM TAB 66100090100320 661000901003 N 1tolterodine SR cap 54100060207020 541000602070 Y 2tolterodine SR cap 54100060207030 541000602070 Y 2tolterodine tab 54100060200320 541000602003 Y 2 RXCtolterodine tab 54100060200330 541000602003 Y 2 RXCTOPAMAX SPRINKLE CAP 72600075006820 726000750068 O 3TOPAMAX SPRINKLE CAP 72600075006830 726000750068 O 3TOPAMAX TAB 72600075000310 726000750003 O 3TOPAMAX TAB 72600075000320 726000750003 O 3TOPAMAX TAB 72600075000330 726000750003 O 3TOPAMAX TAB 72600075000340 726000750003 O 3TOPICORT CREAM 0.05% 90550040003705 905500400037 N 2TOPICORT CREAM 0.25% 90550040003710 905500400037 O 3TOPICORT GEL 90550040004005 905500400040 O 3TOPICORT LP OINTMENT 90550040004203 905500400042 N 3TOPICORT OINTMENT 90550040004205 905500400042 O 3topiramate cap 72600075006820 726000750068 Y 1topiramate cap 72600075006830 726000750068 Y 1TOPIRAMATE ER CAP 7260007500F310 7260007500F3 M M PA_NSOTOPIRAMATE ER CAP 7260007500F320 7260007500F3 M M PA_NSOTOPIRAMATE ER CAP 7260007500F330 7260007500F3 M M PA_NSOTOPIRAMATE ER CAP 7260007500F340 7260007500F3 M M PA_NSO



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITTOPIRAMATE ER CAP 7260007500F350 7260007500F3 M M PA_NSOtopiramate tab 72600075000310 726000750003 Y 1topiramate tab 72600075000320 726000750003 Y 1topiramate tab 72600075000330 726000750003 Y 1topiramate tab 72600075000340 726000750003 Y 1topotecan inj 21550080102120 215500801021 Y M PA_BvDTOPROL XL TAB 33200030057510 332000300575 O 3TOPROL XL TAB 33200030057520 332000300575 O 3TOPROL XL TAB 33200030057530 332000300575 O 3TOPROL XL TAB 33200030057540 332000300575 O 3TORISEL INJ 21532570002020 215325700020 N M NM PA_BvDtorsemide tab 37200080000310 372000800003 Y 1torsemide tab 37200080000320 372000800003 Y 1torsemide tab 37200080000330 372000800003 Y 1torsemide tab 37200080000350 372000800003 Y 1TOUJEO SOLOSTAR INJ 2710400300D230 2710400300D2 N 1TOVIAZ TAB 54100020207520 541000202075 N 3 STTOVIAZ TAB 54100020207530 541000202075 N 3 STtpn electrolyte inj 79992000001300 799920000013 Y M PA_BvDTRACLEER TAB 40160015000320 401600150003 N 2 NM PA QLTRACLEER TAB 40160015000330 401600150003 N 2 NM PA QLtramadol ER tab 65100095107520 651000951075 Y 2 QLtramadol ER tab 65100095107530 651000951075 Y 2 QLtramadol ER tab 65100095107540 651000951075 Y 2 QLtramadol ER tab 65100095107560 651000951075 Y 2 QLtramadol ER tab 65100095107570 651000951075 Y 2 QLtramadol ER tab 65100095107580 651000951075 Y 2 QLtramadol tab 65100095100320 651000951003 Y 1 QLtramadol/acetaminophen tab 65995002200320 659950022003 Y 2 QLTRANDATE TAB 33300010100305 333000101003 O 3TRANDATE TAB 33300010100310 333000101003 O 3TRANDATE TAB 33300010100315 333000101003 O 3trandolapril tab 36100060000310 361000600003 Y 1trandolapril tab 36100060000320 361000600003 Y 1trandolapril tab 36100060000340 361000600003 Y 1trandolapril/verapamil ER tab 36991502700420 369915027004 Y 2trandolapril/verapamil ER tab 36991502700432 369915027004 Y 2trandolapril/verapamil ER tab 36991502700436 369915027004 Y 2trandolapril/verapamil ER tab 36991502700452 369915027004 Y 2tranex acid tab 84100040000320 841000400003 Y 2tranexamic acid IV soln 1000mg/10ml 84100040002025 841000400020 Y M PA_BvD



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITTRANSDERM-SCOP PATCH 50200060008610 502000600086 N 3TRANXENE T TAB 57100030100305 571000301003 O 3TRANXENE T TAB 57100030100310 571000301003 O 3TRANXENE T TAB 57100030100320 571000301003 O 3tranylcypromine tab 58100030100305 581000301003 Y 2TRAVATAN Z OPHTH SOLN 86330070002025 863300700020 N 2 QLTRAVOPROST OPHTH SOLN 86330070002020 863300700020 N 2 QLtrazodone tab 300mg 58120080100325 581200801003 Y 2trazodone tab 50mg, 100mg, 150mg 58120080100305 581200801003 Y 1trazodone tab 50mg, 100mg, 150mg 58120080100310 581200801003 Y 1trazodone tab 50mg, 100mg, 150mg 58120080100315 581200801003 Y 1TREANDA INJ 21100009102010 211000091020 N M NM PA_NSOTREANDA INJ 21100009102030 211000091020 N M NM PA_NSOTREANDA INJ 21100009102120 211000091021 N M NM PA_NSOTRECATOR TAB 09000050000310 090000500003 N MTRELSTAR DEP INJ 3.75MG 21405050201920 214050502019 N M NM PA_BvDTRELSTAR LA INJ 11.25MG 21405050201930 214050502019 N M NM PA_BvDTRELSTAR MIX INJ 21405050201940 214050502019 N M NM PA_BvDTRESIBA INJ 2710400700D210 2710400700D2 N 1TRESIBA INJ 2710400700D220 2710400700D2 N 1tretinoin cap 21708080000110 217080800001 Y 2tretinoin cream 90050030003703 900500300037 Y 2 PAtretinoin cream 90050030003705 900500300037 Y 2 PAtretinoin cream 90050030003710 900500300037 Y 2 PAtretinoin gel 90050030004005 900500300040 Y 2 PAtretinoin gel 90050030004010 900500300040 Y 2 PAtretinoin gel 90050030004015 900500300040 Y 2 PAtretinoin micro gel 90050030204015 900500302040 Y 2 PAtretinoin micro gel 90050030204030 900500302040 Y 2 PATRETIN-X CREAM 90050030003704 900500300037 N 3 PATREXALL TAB 21300050100320 213000501003 N 2TREXALL TAB 21300050100330 213000501003 N 2TREXALL TAB 21300050100340 213000501003 N 2TREXALL TAB 21300050100350 213000501003 N 2TREZIX CAP 659913030501 N 3*triamcinolone cream 90550085103705 905500851037 Y 1triamcinolone cream 90550085103710 905500851037 Y 1triamcinolone cream 90550085103720 905500851037 Y 1triamcinolone lotion 90550085104105 905500851041 Y 1triamcinolone lotion 90550085104110 905500851041 Y 1triamcinolone nasal spray 42200060103210 422000601032 Y 2 QL



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITtriamcinolone ointment 90550085104205 905500851042 Y 1TRIAMCINOLONE OINTMENT 90550085104207 905500851042 N 1triamcinolone ointment 90550085104210 905500851042 Y 1triamcinolone ointment 90550085104215 905500851042 Y 1triamcinolone OTC nasal spray 422000601032 Y 1* OTC QLtriamcinolone spray 90550085103400 905500851034 Y 2triamcinolone/oragel paste 88250020104410 882500201044 Y 1triamterene/hydrochlorothiazide cap 37990002300105 379900023001 Y 1TRIAMTERENE/HYDROCHLOROTHIAZIDE CAP 50-25MG 37990002300110 379900023001 N 2triamterene/hydrochlorothiazide tab 37990002300315 379900023003 Y 1triamterene/hydrochlorothiazide tab 37990002300330 379900023003 Y 1triazolam tab 60201040000305 602010400003 Y 1triazolam tab 60201040000310 602010400003 Y 1TRIAZOLAM TAB 0.125MG 60201040000305 602010400003 N 1TRIBENZOR TAB 36994503450310 369945034503 O 3TRIBENZOR TAB 36994503450320 369945034503 O 3TRIBENZOR TAB 36994503450330 369945034503 O 3TRIBENZOR TAB 36994503450340 369945034503 O 3TRIBENZOR TAB 36994503450350 369945034503 O 3tricitrates soln 562020301020 Y 1*tricon cap 829920052501 Y 1*TRICOR TAB 39200025000310 392000250003 O 3TRICOR TAB 39200025000323 392000250003 O 3trifluoperazine tab 59200085100305 592000851003 Y 1trifluoperazine tab 59200085100310 592000851003 Y 1trifluoperazine tab 59200085100315 592000851003 Y 1trifluoperazine tab 59200085100320 592000851003 Y 1trifluridine ophth soln 86103020002005 861030200020 Y 2TRIGLIDE TAB 39200025000325 392000250003 N 3trihexyphenidyl elixir 73100070101005 731000701010 Y 1trihexyphenidyl tab 73100070100310 731000701003 Y 1trihexyphenidyl tab 73100070100320 731000701003 Y 1tri-legest FE tab 25992003300340 259920033003 Y $0TRILEPTAL SUSP 72600046001820 726000460018 O 2TRILEPTAL TAB 72600046000310 726000460003 O 3TRILEPTAL TAB 72600046000320 726000460003 O 3TRILEPTAL TAB 72600046000340 726000460003 O 3TRILIPIX CAP 39200006006520 392000060065 O 1TRILIPIX CAP 39200006006540 392000060065 O 1trilyte soln 46992004302120 469920043021 Y $0trimethobenzamide cap 50200070100120 502000701001 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITtrimethoprim tab 16000055000305 160000550003 Y 1trimethoprim/polymyxin B ophth soln 86109902602020 861099026020 Y 1trimipramine cap 58200080100105 582000801001 Y 2trimipramine cap 58200080100110 582000801001 Y 2trimipramine cap 58200080100115 582000801001 Y 2tri-nessa lo tab 25992002300310 259920023003 Y $0trinessa tab 25992002300320 259920023003 Y $0TRI-NORINYL TAB 25992002200330 259920022003 O 3TRINTELLIX TAB 58120093100310 581200931003 N 3 QL ST_NSOTRINTELLIX TAB 58120093100320 581200931003 N 3 QL ST_NSOTRINTELLIX TAB 58120093100340 581200931003 N 3 QL ST_NSOTRIOSTAT INJ 28100020102020 281000201020 O M PA_BvDTRISENOX SOLN 21700008102020 217000081020 N M PA_BvDTRIUMEQ TAB 12109903150320 121099031503 N 4 ESP NMtrivora-28 tab 25992002100310 259920021003 Y $0TRIZIVIR TAB 12109903200320 121099032003 O 4TROKENDI XR CAP 72600075007020 726000750070 N M PA_NSOTROKENDI XR CAP 72600075007030 726000750070 N M PA_NSOTROKENDI XR CAP 72600075007040 726000750070 N M PA_NSOTROKENDI XR CAP 72600075007050 726000750070 N M PA_NSOTROPHAMINE INJ 80302010102019 803020101020 O M PA_BvDtropicamide ophth soln 863500500020 Y 1*trospium chloride SR cap 54100065207020 541000652070 Y 2trospium tab 54100065200320 541000652003 Y 2TRULICITY INJ 2717001500D220 2717001500D2 N 3TRULICITY INJ 2717001500D230 2717001500D2 N 3TRUMENBA INJ 1720004012E610 1720004012E6 N $0TRUSOPT OPHTH SOLN 86802340102020 868023401020 O 3TRUVADA TAB 12109902300308 121099023003 N 4 ESP NMTRUVADA TAB 12109902300312 121099023003 N 4 ESP NMTRUVADA TAB 12109902300316 121099023003 N 4 ESP NMTRUVADA TAB 12109902300320 121099023003 N 4 ESP NMTUSNEL C SYRUP 439973033012 N 3* OTCTUSNEL CAP 439975031001 N 3*TUSSICAPS 439952023669 N 3* QLtussigon tab 431010100003 Y 1*tussin DM liquid 439973033209 Y 3* OTCTUSSIONEX SUSP 4399520236G1 O 3* QLTUSSI-ORGANI SYRUP 439970022820 O 3* QLTUSSI-ORGANIDIN DM-S SOLN 439970025209 O 3* OTCTWINJECT INJ 3890004000D530 3890004000D5 M 3 QL ST



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITTWINRIX INJ 17109902051820 171099020518 N $0 PA_BvDTWYNSTA TAB 36993002700320 369930027003 O 3TWYNSTA TAB 36993002700330 369930027003 O 3TWYNSTA TAB 36993002700340 369930027003 O 3TWYNSTA TAB 36993002700350 369930027003 O 3TYBOST TAB 12109530000320 121095300003 N MTYGACIL INJ 16290070002120 162900700021 N M NM PA_BvDTYKERB TAB 21534050100320 215340501003 N 4 ESP NM PA_NSOTYLENOL/CODEINE TAB 65991002050315 659910020503 O 3 QLTYLENOL/CODEINE TAB 65991002050320 659910020503 O 3 QLTYPHIM VI INJ 17200080102020 172000801020 N $0TYSABRI INJ 62405050001320 624050500013 N M NM PA_BvDTYVASO INHALATION SOLN 40170080002020 401700800020 N 2 NM PATYZEKA TAB 12352080000330 123520800003 N MTYZINE NASAL SOLN 42102060102010 421020601020 N MTYZINE PED NASAL SOLN 42102060102005 421020601020 N MUCERIS RECTAL FOAM 89150007003920 891500070039 N 3 PAUCERIS TAB 22100012007530 221000120075 N 3 PA QLULESFIA LOTION 90900004004120 909000040041 N 3ULORIC TAB 68000030000320 680000300003 N 2 RXC STULORIC TAB 68000030000330 680000300003 N 2 RXC STULTRACET TAB 65995002200320 659950022003 O 3 QLULTRAM ER TAB 65100095107520 651000951075 O 3 QLULTRAM ER TAB 65100095107530 651000951075 O 3 QLULTRAM ER TAB 65100095107540 651000951075 O 3 QLULTRAM TAB 65100095100320 651000951003 O 3 QLULTRAVATE CREAM 90550073103710 905500731037 O 3ULTRAVATE LOTION 0.05% 90550073104110 905500731041 N 3ULTRAVATE OINTMENT 90550073104210 905500731042 O 3ULTRESA CAP 51200024006744 512000240067 N 3 STULTRESA CAP 51200024006753 512000240067 N 3 STULTRESA CAP 51200024006758 512000240067 N 3 STUMECTA EMULSION 40% 906600800016 N 3*UMECTA PD EMULSION 40% 906699024016 N 3*UMECTA SUSP 906600800018 O 3*UNASYN BULK PACK 01990002252150 019900022521 O M PA_BvDUNASYN INJ 01990002252120 019900022521 O M PA_BvDurea cream 906600800037 Y NCurea cream 40% 90660080003725 906600800037 Y 1*urea cream 50% 90660080003735 906600800037 Y 1*URECHOLINE TAB 54300010100310 543000101003 O 3 ST



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITURECHOLINE TAB 54300010100320 543000101003 O 3 STURECHOLINE TAB 54300010100330 543000101003 O 3 STURECHOLINE TAB 54300010100340 543000101003 O 3 STUREVAZ CREAM 44% 90660080003729 906600800037 N NCURINE TEST STRIPS 941099000061 N 20%* OTCUROCIT-K TAB 56202010200420 562020102004 O 3UROCIT-K TAB 56202010200440 562020102004 O 3UROCIT-K TAB 56202010200460 562020102004 O 3UROQID #2 TAB 539905022203 N 3*UROXATRAL TAB 56852010107530 568520101075 O 2URSO FORTE TAB 52100040000350 521000400003 O 3URSO TAB 52100040000325 521000400003 O 3ursodiol cap 52100040000120 521000400001 Y 1ursodiol tab 52100040000325 521000400003 Y 2ursodiol tab 52100040000350 521000400003 Y 2uta cap 53992004200140 539920042001 Y NCUVADEX INJ 21707050002020 217070500020 N M PA_BvDVAGIFEM TAB 55350020000310 553500200003 O 3valacyclovir tab 12405085100310 124050851003 Y 2valacyclovir tab 12405085100320 124050851003 Y 2VALCHLOR GEL 90371050204030 903710502040 N 4 ESP NM PA_NSO QLVALCYTE SOLN 12200066102120 122000661021 O 2 NMVALCYTE TAB 12200066100320 122000661003 O 4 NMvalganciclovir soln 12200066102120 122000661021 Y 2 NMvalganciclovir tab 12200066100320 122000661003 Y 2 NMVALIUM TAB 57100040000305 571000400003 O 3VALIUM TAB 57100040000310 571000400003 O 3VALIUM TAB 57100040000315 571000400003 O 3valproate inj 72500020102020 725000201020 Y M PA_BvDvalproic acid cap 72500030000105 725000300001 Y 1valproic acid syrup 72500020101205 725000201012 Y 1valsartan tab 36150080000310 361500800003 Y 1valsartan tab 36150080000320 361500800003 Y 1valsartan tab 36150080000330 361500800003 Y 1valsartan tab 36150080000340 361500800003 Y 1valsartan/hydrochlorothiazide tab 36994002700320 369940027003 Y 1valsartan/hydrochlorothiazide tab 36994002700340 369940027003 Y 1valsartan/hydrochlorothiazide tab 36994002700350 369940027003 Y 1valsartan/hydrochlorothiazide tab 36994002700360 369940027003 Y 1valsartan/hydrochlorothiazide tab 36994002700370 369940027003 Y 1VALTREX TAB 12405085100310 124050851003 O 3



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITVALTREX TAB 12405085100320 124050851003 O 3VANCOCIN CAP 125MG 16000060100110 160000601001 O 3 QL STVANCOCIN CAP 250MG 16000060100120 160000601001 O 3 NM QL STvancomycin cap 16000060100110 160000601001 Y 2 QL STvancomycin cap 16000060100120 160000601001 Y 2 QL STvancomycin inj 16000060102105 160000601021 Y M PA_BvDvancomycin inj 16000060102107 160000601021 Y M PA_BvDvancomycin inj 16000060102108 160000601021 Y M PA_BvDvancomycin inj 16000060102120 160000601021 Y M PA_BvDVANCOMYCIN ORAL SOLN KIT 160000601020 N 2*VANCOMYCIN/DEXTROSE INJ 16000060112020 160000601120 N M PA_BvDVANCOMYCIN/DEXTROSE INJ 16000060112030 160000601120 N M PA_BvDVANCOMYCIN/DEXTROSE INJ 16000060112040 160000601120 N M PA_BvDVANCOMYCIN/DEXTROSE INJ 16000060112080 160000601120 N M PA_BvDVANOS CREAM 90550060003710 905500600037 O 3VAQTA INJ 17100008001860 171000080018 N $0VAQTA INJ 17100008001870 171000080018 N $0VARIVAX INJ 17100087102210 171000871022 N $0 PAVARUBI TAB 50280050200320 502800502003 N 2 PA_BvD QLVASCEPA CAP 39500035100110 395000351001 N M PAVASCEPA CAP 39500035100120 395000351001 N M PAVASERETIC TAB 36991802350310 369918023503 O 3VASOTEC TAB 36100020100303 361000201003 O 3VASOTEC TAB 36100020100305 361000201003 O 3VASOTEC TAB 36100020100310 361000201003 O 3VASOTEC TAB 36100020100315 361000201003 O 3VECTIBIX INJ 21353050002025 213530500020 N M NM PA_BvDVECTIBIX INJ 21353050002035 213530500020 N M NM PA_BvDVECTIBIX INJ 21536015002120 215360150021 N M NM PA_BvDVECTICAL/CALCITRIOL OINTMENT 90250028004220 902500280042 M 2VELPHORO CHEW TAB 52800080100520 528000801005 N 3VELTIN GEL 90059902654020 900599026540 N 3VENCLEXTA TAB 100MG 21470080000360 214700800003 N M NM PA_NSOVENCLEXTA TAB 10MG, 50MG 21470080000320 214700800003 N M PA_NSOVENCLEXTA TAB 10MG, 50MG 21470080000340 214700800003 N M PA_NSOVENCLEXTA TAB STARTING PACK 2147008000B720 2147008000B7 N M NM PA_NSOvenlafaxine ER cap 58180090107020 581800901070 Y 1venlafaxine ER cap 58180090107030 581800901070 Y 1venlafaxine ER cap 58180090107050 581800901070 Y 1VENLAFAXINE ER TAB 58180090107510 581800901075 O 3venlafaxine ER tab 58180090107510 581800901075 Y 1



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITVENLAFAXINE ER TAB 58180090107520 581800901075 O 3venlafaxine ER tab 58180090107520 581800901075 Y 1VENLAFAXINE ER TAB 58180090107530 581800901075 O 3venlafaxine ER tab 58180090107530 581800901075 Y 1VENLAFAXINE ER TAB 225MG 58180090107540 581800901075 M 1venlafaxine tab 58180090100320 581800901003 Y 2venlafaxine tab 58180090100340 581800901003 Y 2venlafaxine tab 58180090100350 581800901003 Y 2venlafaxine tab 58180090100360 581800901003 Y 2venlafaxine tab 58180090100370 581800901003 Y 2VENTAVIS INHALATION SOLN 40170060002020 401700600020 N 2 NM PAVENTAVIS INHALATION SOLN 40170060002040 401700600020 N 2 NM PAVENTOLIN HFA INHALER 00173068220 44201010103410 442010101034 N 2 QLVENTOLIN HFA INHALER 00173068221 44201010103410 442010101034 N 2 QLVENTOLIN HFA INHALER 00173068224 44201010103410 442010101034 N 2 QLVENTOLIN HFA INHALER 00173068254 44201010103410 442010101034 N 2 QLVENTOLIN HFA INHALER 00173068281 44201010103410 442010101034 N 2 QLVERAMYST NASAL SPRAY 42200032101820 422000321018 N 2 QL STverapamil CR tab 34000030100410 340000301004 Y 1verapamil CR tab 34000030100415 340000301004 Y 1verapamil CR tab 34000030100420 340000301004 Y 1verapamil ER cap 100mg, 200mg, 300mg 34000030107015 340000301070 Y 2verapamil ER cap 100mg, 200mg, 300mg 34000030107030 340000301070 Y 2verapamil ER cap 100mg, 200mg, 300mg 34000030107040 340000301070 Y 2verapamil ER cap 120mg, 180mg, 240mg, 360mg 34000030107020 340000301070 Y 1verapamil ER cap 120mg, 180mg, 240mg, 360mg 34000030107025 340000301070 Y 1verapamil ER cap 120mg, 180mg, 240mg, 360mg 34000030107035 340000301070 Y 1verapamil ER cap 120mg, 180mg, 240mg, 360mg 34000030107045 340000301070 Y 1verapamil inj 34000030102005 340000301020 Y M PA_BvDverapamil tab 34000030100303 340000301003 Y 1verapamil tab 34000030100305 340000301003 Y 1verapamil tab 34000030100310 340000301003 Y 1VERDESO FOAM 90550035003920 905500350039 N 3*VERELAN CAP 34000030107015 340000301070 O 3VERELAN CAP 34000030107020 340000301070 O 3VERELAN CAP 34000030107025 340000301070 O 3VERELAN CAP 34000030107030 340000301070 O 3VERELAN CAP 34000030107035 340000301070 O 3VERELAN CAP 34000030107040 340000301070 O 3VERELAN CAP 34000030107045 340000301070 O 3VERIPRED SOLN 22100040202060 221000402020 N 3



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITVERSACLOZ SUSP 59152020001820 591520200018 N MVESICARE TAB 54100055200320 541000552003 N 2 RXCVESICARE TAB 54100055200330 541000552003 N 2 RXCVEXOL OPHTH SUSP 86300070001810 863000700018 N 2VFEND INJ 11407080002120 114070800021 O M PAVFEND SUSP 11407080001920 114070800019 O 3 NM PAVFEND TAB 11407080000340 114070800003 O 3 NM PAVFEND TAB 11407080000320 114070800003 O 3 NM PAV-GO KIT 08560940001 97201030506400 972010305064 N 2* QLV-GO KIT 08560940002 97201030506400 972010305064 N 2* QLV-GO KIT 08560940003 97201030506400 972010305064 N 2* QLVIAGRA TAB 403040701003 N 4* QLVIBRAMYCIN SUSP 04000020001905 040000200019 O 3VIBRAMYCIN SYRUP 04000020201205 040000202012 N 3VIBRAMYCIN TAB 04000020100110 040000201001 O 3VICOPROFEN TAB 65991702500320 659917025003 O 3 QLVICTOZA INJ 2717005000D220 2717005000D2 N 2VIDAZA INJ 21300003001920 213000030019 O M NM PA_BvDVIDEX EC CAP 12105015006520 121050150065 O 4VIDEX EC CAP 12105015006528 121050150065 O 4VIDEX EC CAP 12105015006535 121050150065 O 4VIDEX EC CAP 12105015006550 121050150065 O 4VIDEX SOLN 4GM 121050150021 N 4* ESPVIGAMOX OPHTH SOLN 86101038102020 861010381020 N 2VIIBRYD 10/20/40MG STARTER KIT 58120088106420 581200881064 N M PA_NSOVIIBRYD 10/20MG STARTER KIT 58120088106410 581200881064 N M ST_NSOVIIBRYD TAB 58120088100310 581200881003 N M ST_NSOVIIBRYD TAB 58120088100320 581200881003 N M ST_NSOVIIBRYD TAB 58120088100340 581200881003 N M ST_NSOVIMPAT INJ 10MG/ML 72600036002020 726000360020 N M PA_BvDVIMPAT SOLN 10MG/ML 72600036002060 726000360020 N 2VIMPAT TAB 72600036000320 726000360003 N 2 QLVIMPAT TAB 72600036000330 726000360003 N 2 QLVIMPAT TAB 72600036000340 726000360003 N 2 QLVIMPAT TAB 72600036000350 726000360003 N 2 QLVINBLASTINE INJ 21500030102020 215000301020 N M PA_BvDvincristine inj 21500020102005 215000201020 Y M PA_BvDvinorelbine inj 21500050802020 215000508020 Y M PA_BvDvinorelbine inj 21500050802025 215000508020 Y M PA_BvDVIRACEPT TAB 12104545200320 121045452003 N 4 ESP NMVIRACEPT TAB 12104545200340 121045452003 N 4 ESP NM



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITVIRAMUNE SUSP 00597004724 12109050001820 121090500018 M 4VIRAMUNE TAB 12109050000320 121090500003 O 4VIRAMUNE XR TAB 12109050007510 121090500075 O 4VIRAMUNE XR TAB 12109050007520 121090500075 O 4VIRAZOLE INHALATION SOLN 12604075002120 126040750021 N M NM PA_BvDVIREAD POWDER 12108570102920 121085701029 N MVIREAD TAB 12108570100305 121085701003 N 4 ESP NMVIREAD TAB 12108570100310 121085701003 N 4 ESP NMVIREAD TAB 12108570100315 121085701003 N 4 ESP NMVIREAD TAB 12108570100320 121085701003 N 4 ESP NMVIROPTIC OPHTH SOLN 86103020002005 861030200020 O 3VISTARIL CAP 57200040200105 572000402001 O 3VISTARIL CAP 57200040200110 572000402001 O 3VISTIDE INJ 12200010002020 122000100020 O M NM PA_BvDvitamin D cap 50000unit 77202030000110 772020300001 Y $0*VITAMIN D TAB 400UNIT 77202030000305 772020300003 N $0* OTCvitamin D3 cap 400unit, 1000unit 77202032000105 772020320001 Y $0* OTCvitamin D3 cap 400unit, 1000unit 77202032000110 772020320001 Y $0* OTCVITEKTA TAB 12103020000310 121030200003 N 4 ESP NMVITEKTA TAB 12103020000320 121030200003 N 4 ESP NMVIVELLE-DOT PATCH 24000035008705 240000350087 O 3VIVELLE-DOT PATCH 24000035008710 240000350087 O 3VIVELLE-DOT PATCH 24000035008720 240000350087 O 3VIVELLE-DOT PATCH 24000035008730 240000350087 O 3VIVELLE-DOT PATCH 24000035008750 240000350087 O 3VIVOTIF BERNA CAP 172000800065 N $0* QLVOGELXO GEL PUMP 1% 23100030004040 231000300040 M M PA QLVOLTAREN GEL 90210030304020 902100303040 O 3 QLVOLTAREN XR TAB 66100007207530 661000072075 O 3voriconazole inj 11407080002120 114070800021 Y M PAvoriconazole susp 11407080001920 114070800019 Y 2 PAvoriconazole tab 11407080000320 114070800003 Y 2 NM PAvoriconazole tab 11407080000340 114070800003 Y 2 NM PAVOSPIRE ER TAB 44201010107410 442010101074 O 3VOSPIRE ER TAB 44201010107420 442010101074 O 3VOTRIENT TAB 21534070100320 215340701003 N 4 ESP NM PA_NSOVPRIV INJ 82700085102120 827000851021 N M NM PA_BvDVRAYLAR CAP 59400018100120 594000181001 N M NM PA_NSO QLVRAYLAR CAP 59400018100130 594000181001 N M NM PA_NSO QLVRAYLAR CAP 59400018100140 594000181001 N M NM PA_NSO QLVRAYLAR CAP 59400018100150 594000181001 N M NM PA_NSO QL



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITVRAYLAR CAP THERAPY PACK 5940001810B220 5940001810B2 N M PA_NSO QLVYTORIN TAB 39994002300320 399940023003 N 3 QLVYTORIN TAB 39994002300330 399940023003 N 3 QLVYTORIN TAB 39994002300340 399940023003 N 3 QLVYTORIN TAB 39994002300350 399940023003 N 3 QLVYVANSE CAP 61100025100110 611000251001 N 2VYVANSE CAP 61100025100120 611000251001 N 2VYVANSE CAP 61100025100130 611000251001 N 2VYVANSE CAP 61100025100140 611000251001 N 2VYVANSE CAP 61100025100150 611000251001 N 2VYVANSE CAP 61100025100160 611000251001 N 2VYVANSE CAP 61100025100170 611000251001 N 2warfarin tab 83200030200303 832000302003 Y 1warfarin tab 83200030200305 832000302003 Y 1warfarin tab 83200030200310 832000302003 Y 1warfarin tab 83200030200311 832000302003 Y 1warfarin tab 83200030200313 832000302003 Y 1warfarin tab 83200030200315 832000302003 Y 1warfarin tab 83200030200317 832000302003 Y 1warfarin tab 83200030200320 832000302003 Y 1warfarin tab 83200030200325 832000302003 Y 1WELCHOL PACKET 39100016103040 391000161030 N 2WELCHOL TAB 39100016100330 391000161003 N 2WELLBUTRIN TAB 58300040100305 583000401003 O 3WELLBUTRIN TAB 58300040100310 583000401003 O 3WELLBUTRIN XL TAB 58300040107420 583000401074 O 3WELLBUTRIN XL TAB 58300040107430 583000401074 O 3WELLBUTRIN XL TAB 58300040107440 583000401074 O 3WELLBUTRIN XL TAB 58300040107520 583000401075 O 3WELLBUTRIN XL TAB 58300040107530 583000401075 O 3WESTCORT OINTMENT 90550075204205 905500752042 O 3XALATAN OPHTH SOLN 86330050002020 863300500020 O 3 QLXALKORI CAP 21534015000120 215340150001 N 2 NM PA_NSOXALKORI CAP 21534015000125 215340150001 N 2 NM PA_NSOXANAX TAB 57100010000305 571000100003 O 3XANAX TAB 57100010000310 571000100003 O 3XANAX TAB 57100010000315 571000100003 O 3XANAX TAB 57100010000320 571000100003 O 3XANAX XR TAB 57100010007505 571000100075 O 3XANAX XR TAB 57100010007510 571000100075 O 3XANAX XR TAB 57100010007520 571000100075 O 3



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITXANAX XR TAB 57100010007530 571000100075 O 3XARELTO TAB 83370060000320 833700600003 N 2XARELTO TAB 83370060000330 833700600003 N 2XARELTO TAB 83370060000340 833700600003 N 2XARELTO TAB STARTER PACK 8337006000B720 8337006000B7 N 2XELJANZ ER TAB 11MG 66603065107530 666030651075 N 4 NM PA QLXELJANZ TAB 66603065100320 666030651003 N 4 NM PA QLXELODA TAB 213000050003 O 4* ESPXENAZINE TAB 62380070000310 623800700003 O 2 NM PAXENAZINE TAB 62380070000320 623800700003 O 2 NM PAXERESE CREAM 90359902153720 903599021537 N 3XGEVA INJ 30044530002030 300445300020 N M NM PAXIFAXAN TAB 200MG 16000049000320 160000490003 N 3 QLXIFAXAN TAB 550MG 16000049000340 160000490003 N 3 QLXIGDUO XR TAB 5-1000MG 27996002307515 279960023075 N 2 QLXIGDUO XR TAB 5-500MG, 10-500MG, 10-1000MG 27996002307510 279960023075 N 2 QLXIGDUO XR TAB 5-500MG, 10-500MG, 10-1000MG 27996002307520 279960023075 N 2 QLXIGDUO XR TAB 5-500MG, 10-500MG, 10-1000MG 27996002307525 279960023075 N 2 QLXODOL TAB 65991702100309 659917021003 O 3 QLXODOL TAB 65991702100322 659917021003 O 3 QLXODOL TAB 65991702100375 659917021003 O 3 QLXOLAIR INJ 44603060002120 446030600021 N M NM PAXOPENEX NEB 44201045102510 442010451025 O 3 PA_BvDXOPENEX NEB 44201045102520 442010451025 O 3 PA_BvDXOPENEX NEB 44201045102530 442010451025 O 3 PA_BvDXOPENEX NEB 44201045102560 442010451025 O 3 PA_BvDXTANDI CAP 21402430000120 214024300001 N 4 ESP NM PA_NSO QLXULANE PATCH 25960002508820 259600025088 N $0XYLOCAINE INJ 69100040102010 691000401020 O M PA_BvDXYLOCAINE INJ 69100040102011 691000401020 O M PA_BvDXYLOCAINE INJ 69100040102020 691000401020 O M PA_BvDXYLOCAINE INJ 90850060102015 908500601020 O 3XYREM SOLN 62450060202020 624500602020 N 2 NM QLXYZAL SOLN 41550027102020 415500271020 O MXYZAL TAB 41550027100320 415500271003 O MYASMIN TAB 25990002150320 259900021503 M 3YAZ TAB 25990002150316 259900021503 O 3YERVOY INJ 21353032002020 213530320020 N M NM PA_NSOYF-VAX INJ 17100090002200 171000900022 N $0YODOXIN TAB 140000300003 N 3*YONDELIS INJ 21107075002140 211070750021 N M NM PA_NSO



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITyuvafem tab 55350020000310 553500200003 Y 3zafirlukast tab 44505080000310 445050800003 Y 2zafirlukast tab 44505080000320 445050800003 Y 2zaleplon cap 60204070000120 602040700001 Y 1 QLzaleplon cap 60204070000130 602040700001 Y 1 QLZALTRAP INJ 21335010102020 213350101020 N M NM PA_NSOZALTRAP INJ 21335010102030 213350101020 N M NM PA_NSOZAMICET SOLN 65991702102025 659917021020 N 3 QLZAMICET SOLN 65991702102025 659917021020 O 3 QLZANAFLEX CAP 75100090100110 751000901001 O 3ZANAFLEX CAP 75100090100120 751000901001 O 3ZANAFLEX CAP 75100090100130 751000901001 O 3ZANAFLEX CAP 75100090100320 751000901003 O 3ZANOSAR INJ 21102030002105 211020300021 N M PA_BvDZANTAC INJ 49200020102006 492000201020 N M PA_BvDZANTAC INJ 49200020102007 492000201020 N M PA_BvDZANTAC INJ 49200020102009 492000201020 N M PA_BvDZANTAC TAB 49200020100305 492000201003 O 3ZANTAC TAB 49200020100310 492000201003 O 3ZARONTIN CAP 72400010000105 724000100001 O 3ZARONTIN SOLN 72400010002005 724000100020 O 3ZARXIO INJ 8240152060E530 8240152060E5 N M ESP NM PA_BvDZARXIO INJ 8240152060E540 8240152060E5 N M ESP NM PA_BvDZAVESCA CAP 82700070000120 827000700001 N 2 NMZEBETA TAB 33200022100310 332000221003 O 3ZEBETA TAB 33200022100320 332000221003 O 3ZEGERID CAP 499960026001 O NCZEGERID OTC CAP 11523726501 49996002600120 499960026001 O 1*ZEGERID OTC CAP 11523726502 49996002600120 499960026001 O 1*ZEGERID OTC CAP 11523726503 49996002600120 499960026001 O 1*ZEGERID POWDER PACK 499960026030 O 3*ZELAPAR ODT 73300030107220 733000301072 N 3ZELBORAF TAB 21532080000320 215320800003 N 4 ESP NM PA_NSOZEMPLAR CAP 30905070000110 309050700001 O 3 PA_BvDZEMPLAR CAP 30905070000120 309050700001 O 3 PA_BvDZEMPLAR INJ 30905070002010 309050700020 O M PA_BvDZEMPLAR INJ 30905070002020 309050700020 O M PA_BvDzenatane cap 30mg 55111011381 90050013000130 900500130001 Y 4ZENPEP CAP 51200024006706 512000240067 N 3 STZENPEP CAP 51200024006715 512000240067 M 3 STZENPEP CAP 51200024006715 512000240067 N 3 ST



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITZENPEP CAP 51200024006730 512000240067 N 3 STZENPEP CAP 51200024006748 512000240067 N 3 STZENPEP CAP 51200024006752 512000240067 N 3 STZENPEP CAP 51200024006765 512000240067 N 3 STZENPEP CAP 51200024006785 512000240067 N 3 STzenzedi tab 24338085110 61100020100305 611000201003 Y NCzenzedi tab 24338085310 61100020100310 611000201003 Y NCzeosa tab 25990003600520 259900036005 Y $0ZEPATIER TAB 12359902300320 123599023003 N 4 ESP NM PA QLZERIT CAP 12108070000115 121080700001 O 4ZERIT CAP 12108070000120 121080700001 O 4ZERIT CAP 12108070000130 121080700001 O 4ZERIT CAP 12108070000140 121080700001 O 4ZERIT SOLN 12108070002120 121080700021 O 4ZETIA TAB 39300030000320 393000300003 N 2 QLZETONNA NASAL SOLN 42200018003420 422000180034 N 3 QL STZIAC TAB 36992002130310 369920021303 O 3ZIAC TAB 36992002130320 369920021303 O 3ZIAC TAB 36992002130330 369920021303 O 3ZIAGEN SOLN 12105005102020 121050051020 N MZIAGEN TAB 12105005100320 121050051003 O 4ZIANA GEL 90059902654020 900599026540 O 3zidovudine cap 12108085000110 121080850001 Y 2zidovudine syrup 12108085001210 121080850012 Y 2zidovudine tab 12108085000330 121080850003 Y 2ZINACEF INJ 02200065102105 022000651021 O M PA_BvDZINACEF INJ 02200065102107 022000651021 N M PA_BvDZINACEF INJ 02200065102110 022000651021 O M PA_BvDZINACEF INJ 02200065102115 022000651021 O M PA_BvDZINACEF INJ 02200065102140 022000651021 O M PA_BvDZINACEF/H20 INJ 02200065122010 022000651220 N M PA_BvDzinc sulfate cap 798000100001 Y 1*ZINECARD INJ 21754040002120 217540400021 O M PA_BvDZIOPTAN OPHTH SOLN 86330065002020 863300650020 N 3 QL STziprasidone cap 59400085100120 594000851001 Y 2ziprasidone cap 59400085100130 594000851001 Y 2ziprasidone cap 59400085100140 594000851001 Y 2ziprasidone cap 59400085100150 594000851001 Y 2ZIRGAN OPHTH GEL 86103007004020 861030070040 N 2ZITHROMAX INJ 03400010002120 034000100021 O M PA_BvDZITHROMAX POWDER PACK 03400010003020 034000100030 M 3



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITZITHROMAX SUSP 03400010001920 034000100019 O 3ZITHROMAX SUSP 03400010001930 034000100019 O 3ZITHROMAX TAB 03400010000334 034000100003 O 3ZITHROMAX TAB 03400010000340 034000100003 O 3ZITHROMAX TAB Z-PACK 03400010000320 034000100003 O 3ZMAX SUSP 03400010001970 034000100019 N 3ZOCOR TAB 39400075000310 394000750003 O 3ZOCOR TAB 39400075000320 394000750003 O 3ZOCOR TAB 39400075000330 394000750003 O 3ZOCOR TAB 39400075000340 394000750003 O 3ZOCOR TAB 39400075000360 394000750003 O 3ZOFRAN INJ 50250065052030 502500650520 O M PA_BvDZOFRAN ODT 50250065007220 502500650072 O 3 PA_BvDZOFRAN ODT 50250065007240 502500650072 O 3 PA_BvDZOFRAN SOLN 50250065052070 502500650520 O 3 PA_BvDZOFRAN TAB 50250065050310 502500650503 O 3 PA_BvDZOFRAN TAB 50250065050320 502500650503 O 3 PA_BvDzoledronic acid inj 30042090001320 300420900013 Y M PA_BvDZOLEDRONIC ACID INJ 4MG 30042090002120 300420900021 N M NM PA_BvDzoledronic acid IV soln 30042090002020 300420900020 Y M PA_BvDZOLINZA CAP 21531575000120 215315750001 N 4 ESP NM PA_NSOzolmitriptan ODT 67406080007220 674060800072 Y 2 QLzolmitriptan ODT 67406080007230 674060800072 Y 2 QLzolmitriptan tab 67406080000320 674060800003 Y 2 QLzolmitriptan tab 67406080000330 674060800003 Y 2 QLZOLOFT CONC 58160070101320 581600701013 O 3ZOLOFT TAB 58160070100305 581600701003 O 3ZOLOFT TAB 58160070100310 581600701003 O 3ZOLOFT TAB 58160070100320 581600701003 O 3zolpidem tab 60204080100310 602040801003 Y 1 QLzolpidem tab 60204080100315 602040801003 Y 1 QLZOMETA INJ 30042090001320 300420900013 O M NM PA_BvDZOMETA INJ 30042090002016 300420900020 N M NM PA_BvDZOMIG NASAL SPRAY 67406080002010 674060800020 N 3 QLZOMIG NASAL SPRAY 67406080002020 674060800020 N 3 QLZOMIG TAB 67406080000320 674060800003 O 3 QLZOMIG TAB 67406080000330 674060800003 O 3 QLZOMIG ZMT TAB 67406080007220 674060800072 O 3 QLZOMIG ZMT TAB 67406080007230 674060800072 O 3 QLZONEGRAN CAP 72600090000105 726000900001 O 3ZONEGRAN CAP 72600090000120 726000900001 O 3



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITzonisamide cap 72600090000105 726000900001 Y 1zonisamide cap 72600090000110 726000900001 Y 1zonisamide cap 72600090000120 726000900001 Y 1ZONTIVITY TAB 85155780300320 851557803003 N 3 PAZORTRESS TAB 99404035000320 994040350003 N 2 PA_NSOZORTRESS TAB 99404035000325 994040350003 N 2 PA_NSOZORTRESS TAB 99404035000330 994040350003 N 2 PA_NSOZOSTAVAX INJ 17100095102120 171000951021 N $0 PAZOSYN INJ 01990002702120 019900027021 O M PA_BvDZOSYN INJ 01990002702130 019900027021 O M PA_BvDZOSYN INJ 01990002702140 019900027021 O M PA_BvDZOSYN INJ 01990002702170 019900027021 O M PA_BvDZOSYN/DEXTROSE INJ 01990002722020 019900027220 N M PA_BvDZOSYN/DEXTROSE INJ 01990002722025 019900027220 N M PA_BvDZOSYN/DEXTROSE INJ 01990002722030 019900027220 N M PA_BvDzotane hydrocortisone otic soln 879920031420 Y 1*zovia tab 25990002200320 259900022003 Y $0ZOVIRAX CAP 12405010000110 124050100001 O 3ZOVIRAX CREAM 90350010003720 903500100037 N 3ZOVIRAX OINTMENT 90350010004205 903500100042 O 2ZOVIRAX SUSP 12405010001810 124050100018 O 3ZOVIRAX TAB 12405010000320 124050100003 O 3ZOVIRAX TAB 12405010000330 124050100003 O 3ZUTRIPRO LIQUID 439953035420 O 3* QLZYBAN SR TAB 62100002107430 621000021074 O $0ZYCLARA CREAM 90773040003710 907730400037 N MZYCLARA CREAM 90773040003715 907730400037 N MZYDELIG TAB 21538040000320 215380400003 N 2 PA_NSOZYDELIG TAB 21538040000330 215380400003 N 2 PA_NSOZYFLO CR TAB 44504085007420 445040850074 N 3ZYFLO TAB 44504085000330 445040850003 N 3ZYKADIA CAP 21534014000130 215340140001 N M NM PA_NSOZYLET OPHTH SUSP 86309902171820 863099021718 N 2ZYLOPRIM TAB 68000010000305 680000100003 O 3ZYLOPRIM TAB 68000010000310 680000100003 O 3ZYMAXID OPHTH SOLN 86101029002030 861010290020 O 3 STZYPREXA INJ 59157060002120 591570600021 O M PA_BvDZYPREXA INJ 59157060101950 591570601019 N M PA_BvDZYPREXA TAB 59157060000305 591570600003 O 3ZYPREXA TAB 59157060000310 591570600003 O 3ZYPREXA TAB 59157060000315 591570600003 O 3



Product Identifier TypePUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE CODE TIER DRUG EDITZYPREXA TAB 59157060000320 591570600003 O 3ZYPREXA TAB 59157060000330 591570600003 O 3ZYPREXA TAB 59157060000340 591570600003 O 3ZYPREXA ZYDIS TAB 59157060007210 591570600072 O 3ZYPREXA ZYDIS TAB 59157060007220 591570600072 O 3ZYPREXA ZYDIS TAB 59157060007230 591570600072 O 3ZYPREXA ZYDIS TAB 59157060007240 591570600072 O 3ZYTIGA TAB 21406010200320 214060102003 N 4 ESP NM PA_NSOZYVOX IV SOLN 16230040002030 162300400020 N M NM PAZYVOX IV SOLN 16230040002040 162300400020 O M NM PAZYVOX IV SOLN 16230040102040 162300401020 N M NM PAZYVOX SUSP 100MG/5ML 16230040001920 162300400019 O 2 NM PAZYVOX TAB 16230040000330 162300400003 O 3 NM PA

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PUBLISHED DRUG NAME NDC GPI-14 GPI-12 MULTISOURCE … · Attachment H - EGWP Formulary RFP ETG0013 – Administrative Services for the State of Wisconsin Pharmacy Benefit Program